Canberra Hospital is at risk of ineffectively managing a major disaster - like a mass casualty event - in part due to outdated policies and unclear roles.
Among the problems revealed in an internal document obtained by The Canberra Times was that the hospital's chemical decontamination tent had not been maintained and no one was trained to erect it.
Canberra Health Service's integrated risk register, released through freedom of information laws, listed the risk of "ineffective response to and recovery from complex level two and three emergency incidents" as high.
The service's CEO Bernadette McDonald said she was confident the hospital had the systems and processes in place to respond to complex emergency incidents as they occurred.
"Risk management is a positive, proactive process that identifies opportunities for improvement," she said.
Level three emergency incidents include external emergencies like mass casualty events or a pandemic, while level two emergencies are generally internal.
The register said the risk was in part created by the fact plans and policies were outdated after ACT Health split into two departments last year. The risk had the potential for harm to patients, staff and visitors, the register said.
The document said roles and responsibilities were unclear within the incident management team and there had been inadequate opportunity for major incident and business disruption event training exercises.
It said protective equipment needed for chemical, biological, radiological and nuclear decontamination was out of date and ACT Fire and Rescue was unable to advise what equipment was required.
A decontamination tent was not properly maintained and there were no staff who had been trained to set it up.
A new interim chemical, biological, radiological and nuclear response has been created guiding emergency department staff in decontamination techniques, the documents said.
Interim documents have also been created for mass casualty events with a plan to create a new department wide procedure.
The register said the health service aimed to reduce the overall risk to medium.
Australian Strategic Policy Institute senior analyst Anthony Bergin said the situation was likely to be replicated at hospitals across the country.
He said while he did not have knowledge relating to Canberra Hospital specifically, there should be a greater focus from health and security officials about the role of hospitals in mass casualties events.
Dr Bergin suggested creating a public register, which would allow people to compare how prepared the country's major hospitals were for mass casualty events like terrorist attacks or natural disasters.
He said hospitals should conduct realistic and no notice disaster management exercises.
"The other thing I would highlight is of course hospitals themselves have come under attack in a number of overseas terrorism incidents," he said.
A Canberra Health Services spokeswoman said the organisation believed the risk would decrease later this year as a result of work currently underway.
"Canberra Hospital is an operational tertiary level campus, which provides service 24 hours a day, seven days a week. Due to this reason ... it would be inappropriate to run major incident response exercises regularly. That said, planning is currently underway for a major incident response exercise later this year," she said.
"Risk registers are about being proactive and honest about all potential risks to our services and this ensures we plan properly to respond if we need to.
"The ACT Government is committed to robust risk management practices, recognising that risk management is an integral part of good management. The safety of our patients, staff and our visitors in our services will always be a priority."