Canberra Hospital risks losing its accreditation unless it urgently addresses dozens of problems, including some that were found to have placed patients at extreme risk.

The ACT Government has released an interim accreditation report which found the Canberra Hospital failed to meet 33 core criteria.

Two of those criteria are ranked as extreme risk, while six are listed as high.

The hospital has until July to rectify the issues to maintain its accreditation under national standards assessed by The Council of Healthcare Standards.

Interim director-general of ACT Health, Michael De'ath, said he convened an "extremely high level" group of senior executives to ensure the criteria are met within 90 days.

"Not being accredited is not an option for us," he said.

The hospital achieved 176 of the 209 core criteria.

'Extreme risk to patients'

The review found patients were placed at "extreme risk" by a failure to immediately carry out robust reviews following four suicides on the mental health ward and one in a general medical ward.

It also said there appeared to be no regular audits of high-risk areas within the wards.

The ACT Government said it has already engaged contractors to address that issue.

Other risks: Health risk to staff at the Hume Health Centre due to high levels of smoking by inmates

Health risk to staff at the Hume Health Centre due to high levels of smoking by inmates Errors in specimen labelling occur "regularly"

Errors in specimen labelling occur "regularly" Surgical safety checklist not routinely completed, leaving risk of injury from wrong surgery

Surgical safety checklist not routinely completed, leaving risk of injury from wrong surgery No clear strategic plan and delays in decision making could impact on patient safety

No clear strategic plan and delays in decision making could impact on patient safety Staff not clearly informed of accountabilities and responsibilities in safety, quality and risk

Mental Health Minister Shane Rattenbury said the adult mental health facility remained the safest place in Canberra for anyone at risk of suicide.

"Notwithstanding that we've got some risks to deal with, it's still the best place for them to be in terms of that supervision," he said.

The report recommended an urgent independent external review of all mental health inpatient units, drug and alcohol and justice health facilities to assess safety and risk to consumers.

ACT Health said it was in the process of commissioning experts to undertake the review.

Four of the suicides are currently being examined by the ACT Coroner.

The report found there was good evidence of mechanisms to identify patients at risk of other medical events like falls, deterioration or blood transfusions.

The Government said it was "not uncommon" for hospitals around the country to receive an interim report with criteria that had not been met during the accreditation process.

The interim findings have been released ahead of next week's final report.

Health Minister Meegan Fitzharris said the public should have full confidence in the hospital.

"If I or my kids got sick, it's the first place I'd take them," she said.

"We want to let people know that they absolutely can seek treatment at ACT Health facilities, that there's an ongoing process of improvement and that this is not a process that they should in any way be alarmed about."

High risk of legionella outbreak

The report noted "significant concerns" over a potential problem with two levels of one building maintaining hot water, which could create an environment for a legionella outbreak.

Despite the risk being identified in December 2016 following positive samples and a risk control action plan being in place, it found there had been "poor progression of the plan".

"Considering the vulnerable patient's cohort in [the building] and lack of evidence around action of disinfection and progress against risk mitigation, the risk is rated as high," the report said.

"An event might occur and the consequence would be high with potential of significant infections to vulnerable patients."

Legionella bacteria is responsible for a type of pneumonia called Legionnaires' disease.

Despite a food safety audit in August noting dusty ceiling vents, bugs and vermin in light fittings, dirty flooring, pooling of water on the floor and poor bench cleaning, surveyors said they found similar conditions during the accreditation process.

Hospital governance criticised

Of the 33 criteria that were not met, ACT Health said 17 related to governance issues.

The report noted a "major policy gap" between corporate and clinical governance and confusion about the responsibilities of ACT Health and The Canberra Hospital.

ACT Health is currently undergoing a restructure which will split the directorate into two separate areas, one dealing with clinical management and the other focusing on policy.

The president of the Australian Medical Association's ACT branch, Steve Robson, said patients in Canberra's health system could rest assured that clinical staff working in those facilities were not the issue.

"They have great staff working very hard and the staff all have patient care as their foremost priority, and that's not going to change," he said.

"These accreditation visits are designed to improve even further the care. It's no reflection on the staff, it's the way that the systems in place can be brought into line with best practice."

Ms Fitzharris said the concerns around how hospitals are run reaffirmed the Government's decision to undertake the restructure of ACT Health.

The report noted a "significant degree of churn" in senior executives over the past few years which resulted in instability and lack of consistency in quality management.

It also acknowledged the Government's new quality strategy, which was launched the week prior to the survey, but said there was not yet a plan to support the framework.

Australian public hospitals are required to meet National Safety and Quality Health Service Standards, which were endorsed by state and territory ministers in 2011.

Surveyors conducted an organisation-wide review for one week in March, which included engaging with staff that the hospital to determine if the standards were being met.

The hospital was last accredited in 2015, and that accreditation will remain in place until July.