Information

  • Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

Staff Interiew

  • Staff know how to access Infection Prevention Policies

  • Staff know the location of the Exposure Control Plan / Tuberculosis Control Plan

  • Staff are knowledgable about the blood spill protocol and which disinfectant to use, along with the kill time

  • Proper reporting of exposures (report immediately, complete UOR, report to Employee Health, notify supervisor / manager

  • What is done when you identify an empty hand sanitizer dispenser

  • What is done when you identify a full sharp disposal container

  • How is linen taken from the clean utility room to the patient's room

  • How is water taken from the ice/water machine to the patient's room

  • What items are disposed of in the red biohazard containers

  • When are refrigerator(s) defrosted/cleaned

Department Rounds

  • Have an employee demonstrate soap/water hand washing...20 seconds, paper towel to turn of water / open door

  • Have an employee demonstrate the use of alcohol gel before entering/exiting a patient room

  • Handwashing between patients, after patient contact after glove removal, after personal breaks

  • Gloves not worn in the hallway

  • Gurneys are cleaned after use with appropriate disinfectant<br>(ER, SDS, Radiology)

  • Clean linen is covered and maintained in a clean/dry area

  • Disposable blood pressure cuffs not used for routine patient care<br>(exception SDS/OR/PACU)

  • Soiled linen is placed in designated covered hampers

  • Clean utility is separate from dirty utility

  • 18 inches of clearance from ceiling in clean utility room or other clean areas

  • All sterile supplies are dry with intact packaging, not stored on the floor

  • Low storage areas must have solid surface shelving

  • Storage of sterile supplies 8-10" above the floor, 2" away from exterior walls

  • Under sink storage is limited to waste and disinfectants / cleaners

  • Environment and equipment is clean and dust free

  • Crash cart is dust free

  • Crash cart- gloves immediately available

  • Crash Cart- sharps disposal

  • Crash Cart- last date checked documented

  • Crash Cart- Date of last defib strip

  • Crash Cart- date of 1st medication outdate

  • Accucheck monitor docked

  • Accucheck case and machine clean

  • Date last QC done

  • open date of high control or expiration date

  • open date of low control or expiration date

  • date test strips opened

  • No eating or drinking in the patient care area

  • Clean equipment is labeled clean / clean tag is removed prior to use

  • Shipping boxes not stored with supplies/ removed from clean areas

  • Soap dispensers are full and functional

  • Purell dispensers are full and functional

  • General appearance of the area is clean and uncluttered

  • Hampers used appropriately- ie. not bags on the floor, no overflowing linen

  • Ceiling tiles are clean and dry

  • Cleaning supplies are labeled and approved for use in the hospital

  • Urine collection bags (Foley) are not touching the ground

Medication Room

  • Refrigerator is labeled as "medication" refrigerator

  • Thermometer present

  • Multi-dose vials approved for multi-patient use

  • Opened vials labeled and dated

  • Expired medications? What? Removed and taken to pharmacy. Given to...

  • Safety devices are used for all injections, phelbotomy, venipuncture, & IV therapy. Exceptions to safety devices...

  • Sharps containers are accessible, secured to wall/counter and emptied when reach "full" line

  • Sterile irrigation fluid is opened for same day use only (<24hr). Date noted.

  • Other irrigation / prep fluids labeled and dated

  • Glass is disposed of in rigid sharps containers

  • Single use medication vials discarded

  • IV tubing labeled with date

Patient Room

  • Inspect patient rooms and bathrooms for inappropriate supplies or outdated supplies

  • Gloves boxes filled

  • Sharps container less than 3/4 full

  • Hand sanitizer at least 1/2 full

  • Soap at least 1/2 full

  • Garbage can with liner

  • No soiled linen on the floor

  • If bed is unmade- mattress intact?

Isolation Room / Cart

  • CDC isolation guidelines are available on isolation carts or other designated area in the department

  • Cart present

  • Correct sign on door

  • Adequate amount of supplies available

  • Only isolation supplies in the drawers

  • Hand sanitizer available and full

  • Wastebasket inside doorway

  • PPE worn correctly

  • Removed prior to leaving patient room

  • If negative pressure- PAPR hood utilized

  • If negative pressure- check logbook in maintenance- when on pressure to be checked/documented every shift by engineer

  • Equipment used in the isolation room is wiped down after use, before taking into another patients room<br>(dynamaps, thermometers, computers, stethoscope, etc.)

Refrigerators- staff and patient

  • Staff refrigerator is labeled "STAFF"

  • Thermometer present

  • Temperatures logged every day prior to today's date: dates temperatures not checked

  • Staff food/ containers identified

  • Open condiments labelled with staff's name and open date

  • Patient refrigerator is labled "PATIENT"

  • Thermometer present

  • Temperatures logged every day prior to today's date; dates temperatures not checked

  • Clean

  • No expired food

  • If applicable patient's food identified with name and bed #

Clean Utility Room

  • Clean items only

  • No medical supplies on floor

  • No medical supplies left in original shipping container

  • Nothing stored under the sinks

  • Check for outdated supplies

  • Door closed

Dirty Utility Room

  • Dirty items only

  • Door closed on soiled utility room

  • No storage of drinking cups, tissues, paper towels, toilet tissue

  • No hoses touching in floor drains

  • PPE available

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.