Healthcare risk assessments should be reviewed at least yearly and whenever services, staff, incidents, laws, or technology change.
Risk shifts fast in clinics, hospitals, and care homes. New staff arrive. Treatments change. Software updates land. A tidy plan from last spring can miss today’s hazards. So the real answer to how often you should review a risk assessment in healthcare is twofold: keep a clear baseline cycle, and run extra checks when something changes.
How Often To Review A Healthcare Risk Assessment: Practical Cadence
Start with a dependable rhythm. Most organizations work well with an annual full review, plus lighter check-ins across the year. Pair that with prompt reviews after any change, near miss, or breach. The cadence below balances compliance, clinical reality, and workload.
| Risk Area | Minimum Review | Triggered Review Events |
|---|---|---|
| Exposure to bloodborne pathogens | Annual plan update | New sharps, new procedures, device changes, needlestick trends |
| Information security (ePHI) | Ongoing; formal review each year | New systems, vendors, data flows, cyber alerts, ransomware activity |
| Medication use and storage | 6–12 months | Formulary updates, high-alert meds added, storage layout changes |
| Infection prevention practices | 6–12 months | Outbreaks, new guidance, ventilation or workflow changes |
| Manual handling and falls | 6–12 months | Patient mix shifts, equipment upgrades, injury patterns |
| Fire and life safety | Annual | Construction, occupancy changes, alarm or door hardware updates |
| Radiation and imaging | Annual | New units, protocols, shielding work, dose audit results |
Why yearly? A full cycle aligns with budgeting, training, and audit windows. It also lets you record trends, close actions, and reset targets. Still, the yearly mark is the floor, not the ceiling.
Why Annual Isn’t Enough In Healthcare
Risk profiles shift fast with new services, staffing gaps, seasonal surges, or vendor changes. Cyber threats rise and fall week by week. A standing date alone can’t keep up. That’s why change-driven reviews sit alongside calendar-driven reviews.
Trigger Events That Demand An Immediate Review
- New or changed care pathways, devices, or high-risk procedures
- Incidents, near misses, or audit findings
- Staffing changes that affect supervision or skill mix
- New software, vendors, or data sharing routes
- Construction, layout shifts, or building works
- New laws, guidance, or payer rules
Set a rule of thumb: if a change alters hazards, controls, people, or places, a review is due.
How Often Should You Review Your Risk Assessment In Healthcare — Real-World Schedules
Use tiered timing. Units with higher hazard levels need tighter cycles. Pair a rolling log of changes with a monthly huddle so issues get flagged early.
Tier 1: High-Risk Areas
Think emergency, operating rooms, oncology, dialysis, and labs handling sharps and cytotoxics. Run quarterly risk checks here, with a short action review each month. Keep a live list of top risks and evidence of controls in place. When the unit adds a new device or protocol, run a focused mini-assessment within two weeks.
Tier 2: Moderate-Risk Areas
General wards, clinics, and imaging typically fit here. A six-month review works, with a brief mid-cycle check for staffing or layout changes. Track key indicators: meds errors, falls, hand hygiene, privacy alerts, and work injuries. If trends jump, move the review forward.
Tier 3: Lower-Risk Areas
Admin suites, archives, and meeting spaces still carry risks—data, fire safety, lone working. Complete a yearly review and capture any changes through your change log. If an office shifts to new software or moves desks, add a quick review.
Align With The Rules You Must Follow
Some domains set a hard floor. The OSHA Bloodborne Pathogens standard makes the exposure control plan a living document that must be reviewed and updated at least once a year and when tasks or roles change. That ties directly to sharps safety and post-exposure steps. For digital risks, HHS guidance under the HIPAA Security Rule frames risk analysis as an ongoing process, with updates when systems, threats, or practices change. Link your local policy to both so your cadence stands up during surveys. See the OSHA Bloodborne Pathogens standard and HHS’s Guidance on Risk Analysis.
Also blend sector guidance for infection prevention. Policies should be kept current and updated when practice or requirements shift. Build this into your schedule so outbreak lessons turn into refreshed controls without delay.
Build A Simple Review Calendar That Sticks
Pick Owners And Backups
Name a single owner for each risk domain, plus a deputy. Owners run reviews, log actions, and present evidence. Deputies keep momentum when people move or take leave.
Inventory Every Risk Assessment You Hold
List each assessment with its scope, last review date, risk level, and required evidence. Add where records live and who signs them. This turns a pile of files into a clear plan.
Set Cadence By Risk Level
Map Tier 1/2/3 timing to each entry. Add triggered review rules. Example: “Any new vendor that touches ePHI prompts a HIPAA risk review within 30 days.”
Automate Reminders
Use your EHR tasking tool, a calendar, or GRC software. Send owners a 30-day heads-up, a 7-day nudge, and a due-date prompt. Keep missed dates visible on a dashboard.
Tie Reviews To Change Control
Add one checkbox to your change request form: “Does this change require a risk assessment review?” If yes, assign it and set a short deadline.
Close The Loop With Evidence
For each review, capture what you checked, what changed, the new risk rating, and proof that controls work. Store minutes, photos, training logs, audit runs, or vendor attestations in one place.
Annual Risk Review Checklist
| Task | What To Check | Evidence To Save |
|---|---|---|
| Scope and hazard list | All tasks, people, and places still in scope | Updated process map, staff list, floor plan |
| Control measures | Are controls still the best choice? | Photos, maintenance logs, device models |
| Training and drills | Staff covered, refresh dates met | Sign-in sheets, LMS exports, drill reports |
| Incidents and trends | Near misses, audit gaps, RCA outputs | Incident log, action tracker, closure proof |
| Vendors and data flows | New systems or contracts in play | BAA list, data map, access reviews |
| Legal and guidance changes | New rules or alerts in the last year | Policy updates, bulletin archive |
| Sign-off and sharing | Leaders and staff briefed on changes | Sign-off page, briefing slides |
How To Document And Prove Your Review
Your file should stand alone in a survey, complaint, or claim. Use a short template so every reviewer writes the same way. Keep version control tight and label files so anyone can find them fast.
What A Solid Record Looks Like
- Title, scope, owner, dates, and version number
- Hazards, people at risk, and existing controls
- Risk ratings with method noted
- What changed since the last round
- Actions, owners, and due dates
- Attachments: photos, logs, screenshots, vendor letters
- Sign-off and distribution list
Keep email trails out of the main record. Save clean copies of source files. If your system allows links, add them, but store a PDF snapshot too.
Common Pitfalls That Get Facilities Cited
- One-and-done risk assessments that never get reviewed
- Reviews that swap in new text but keep old controls
- No link between changes in care and the review list
- Weak evidence that controls work in practice
- Gaps between policy words and what staff do
- Missed vendor impacts on data, access, or uptime
- Missing proof of staff training on new controls
90-Day Plan To Raise Your Review Game
Days 1–30
Build the inventory and assign owners. Pull last review dates and risk levels. Flag red items past due. Publish the first cut of your calendar and circulate it to leads.
Days 31–60
Run reviews in two high-risk areas and one moderate area. Fix the quick wins. Add any needed drills or refreshers to the training plan. Tighten your change form so review triggers fire every time.
Days 61–90
Complete the yearly review pass on low-risk areas. Close actions from month one. Hold a short lessons meeting and update the playbook. Lock in next year’s dates.
What “Good” Looks Like During A Survey
Surveyors want to see a living cycle, clear owners, prompt updates after change, and evidence that staff follow the plan. They also look for proof that digital risks are assessed with care and that sharps risks are reviewed each year.
Helpful Sources You Can Cite In Policy
For sharps and exposure risks, anchor your yearly review in the OSHA Bloodborne Pathogens standard. For digital risks, cite HHS guidance that frames the HIPAA risk analysis as ongoing with updates “as needed.” For infection prevention, align your cycles with CDC core practices and written policy upkeep. Linking your cadence to these references gives your schedule a firm base.
Finally, post your calendar, keep your change log current, and make it easy for staff to raise hazards. With a steady cycle and quick triggered reviews, your risk assessments will stay fresh, auditable, and useful on the floor.