Risk Assessments Drive Emergency Showers, Eyewash Stations
By Richard Parker, MBA, CHFM, FACHE, FASHE, Associate Director
Richard Parker is Associate Director of Life Safety and Physical Environment at ACHC. His range of experience makes him ideally suited to provide standards interpretation, post-survey support, and client education. Prior to joining ACHC, Richard’s work in hospitals included department responsibilities in engineering, construction, security, environmental services, food and nutrition services, patient transport, laundry and linen services, and communications.
Posted: March 2, 2026
Eyewash stations and emergency showers are critical safety features when staff work with corrosive or injurious materials. However, ACHC Accreditation surveys consistently show confusion about when these devices are required, how they must perform, and how they should be maintained. ACHC Hospital Accreditation Standard 11.01.06 (Critical Access Hospital Accreditation Standard 03.01.06) establishes a clear, risk-based approach that many hospitals overlook.
Understanding and applying this standard correctly can reduce unnecessary equipment, improve staff safety, and prevent avoidable survey findings.
The standard in practice
Standard 11.01.06 (03.01.06) requires hospitals to identify locations where staff may be exposed to corrosive materials and to determine, through a documented risk assessment, whether eyewash stations or emergency showers compliant with ANSI Z358.1-2014 are needed. When installed, equipment must activate within one second and deliver tepid water between 60 and 100 degrees Fahrenheit. Weekly activation and annual inspection or testing must be documented.
The key point is that installation is not automatic. It is driven by risk assessment.
Why findings occur
Survey findings related to eyewash stations and emergency showers typically fall into three categories.
First, corrosive chemicals are present without a documented risk assessment. Common examples include laundry mechanical rooms, sterile processing areas, boiler rooms, and receiving or supply areas where chemicals are mixed or transferred.
Second, the equipment is installed but does not meet ANSI performance requirements. This includes eyewash units supplied only with cold water, units without a thermostatic mixing valve, or devices that require manual adjustment to reach a tepid temperature.
Third, documentation is incomplete. Weekly activation logs may be missing, annual inspection reports may not be available, or failed inspections may lack documented corrective action.
Another frequent issue is the use of portable eyewash bottles instead of a plumbed, ANSI-compliant unit. Bottles may serve as immediate first aid, but they do not meet ANSI requirements. Without a risk assessment explaining why a plumbed eyewash unit is not required, use of portable eyewash bottles often results in citations.
Top compliance tips
Evaluate each department where chemicals are used, stored, or mixed. Assess splash potential, chemical concentration, and likelihood of eye or body exposure. Document the decision-making process clearly.
Many hospitals maintain more eyewash stations than necessary. Excess equipment increases the burden of weekly and annual tasks and raises the risk of missed documentation.
Eyewash stations and emergency showers must meet all requirements of ANSI Z358.1-2014. Units that cannot maintain tepid water or activate within one second are not compliant.
Revisit risk assessments during the annual Safety Program evaluation. Changes in chemical use often justify the removal of equipment that is no longer required.
A real-world example
In one hospital’s central processing area, staff mixed concentrated detergents. An eyewash station was present, but staff had to manually adjust the hot and cold valves to reach a tepid range, and the activation time exceeded one second. The unit failed ANSI criteria and resulted in a citation. Corrective action included installing a thermostatic mixing valve, updating preventive maintenance procedures, and retraining staff to report performance issues.
Final takeaway
Compliance with Standard 11.01.06 (03.01.06) depends on accurate risk identification, proper equipment selection, and disciplined follow-through. Documented risk assessments prevent unnecessary installations, reduce missed maintenance tasks, and strengthen a hospital’s position during surveys and after exposure events.
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