Title Page

  • Conducted on

  • Prepared by

  • Location

  • Unit

  • Types of Staff Interviewed (RN, Tech, EVS, Pharmacist, etc.)

Staff & Staff Knowledge

  • All staff must wear names badges at chest level with photo ID visible

  • Staff can identify nearest fire alarm pull station.

  • Staff know the location of the nearest fire extinguisher.

  • Staff can verbalize how to use a fire extinguisher (P.A.S.S.)

  • Staff can describe what to do in case of fire (R.A.C.E.).

  • Staff know the process for notifying primary care physicians and/or family of their hospitalization if asked by the patient.

  • Pt information (White board, WOWs & Chart) secured to ensure privacy

  • Check for expired meds or supplies throughout the unit

  • Staff are using 2 patient identifiers in compliance with hospital policy (patient identification, specimen labeling, etc.)

  • No other non-compliant findings.

EOC Exits & Egress

  • Egress is clear. Exit doors are not blocked and clear of clutter

  • Fire rated doors must latch & close properly

  • No flammable items on fire rated doors

  • Hallways clear with all equipment parked on one side or in alcoves

  • Nothing in front of medical gas valves, fire extinguishers or pull stations

  • No doorstops used or doors propped open

  • No food or beverages in patient care areas or nurse‚Äôs stations

  • No supplies stored within 18 inches from bottom of sprinkler head

  • No unattended meds on Pyxis, WOWs, or throughout the unit

  • All Pt. equipment labeled with clinical engineering sticker & current PMs

  • O2 tanks upright in holder, full and empty tanks separated with signage

  • No other non-compliant findings.

Med Room

  • Med Prep areas are clean, uncluttered and separated from other areas

  • Med rooms locked with access for authorized personnel only

  • All insulin or multi-use vials are dated w/discard date in 28 days

  • Pill cutters are individual use only. Must be labeled with patient name

  • Med refrigerator and freezer temp logs documented daily

  • Out of range temperatures are addressed.

  • Med room checked for expired meds & supplies

  • No other non-compliant findings.

Crash Cart

  • Defibrillator is plugged in.

  • Crash Cart tidy and clean. No dust or excessive supplies on crash carts

  • Crash cart logs and Defibrillator check documented daily. Lock is intact and matches log documentation.

  • Patches for leads are closed and sealed in their original packages.

  • No other non-compliant findings.

Waived Tests

  • Glucometers cleaned, Controls and Strips dated w/date opened/expiration date; toss after 90 days

  • No expired supplies.

  • No other non-compliant findings.

Infection Control

  • Staff can verbalize or demonstrate proper donning and doffing of PPE.

  • Contact Precaution sign posted and isolation cart placed outside of room

  • Overall cleanliness of unit (floors, walls, clutter, dust)

  • Nothing stored under sinks throughout unit

  • Hand hygiene performed when staff entering & exiting patient rooms

  • Hand gel stocked in all dispensers

  • No open Sani-Cloth containers

  • No gloves, booties, hanging face masks while in hallway or public areas

  • No other non-compliant findings.

Patient Pantry/Kitchen

  • Patient food must be labeled with Pt. name and date

  • No staff food to be stored in patient refrigerator

  • Refrigerator temp checked daily & documented daily by dietary services

  • No other non-compliant findings.

Clean Utility Room

  • Linen carts must be covered and have solid bottoms

  • All linen and supply carts must have solid bottom on lower shelf

  • No supplies stored on the floor. Must be on pallets or wire shelving

  • No corrugated shipping boxes. Remove immediately

  • No other non-compliant findings.

Soiled Utility Room

  • Equipment requiring cleaning or service must be clearly marked

  • Used instruments for reprocessing are stored in a biohazardous-labeled rigid container and wet with enzymatic detergent.

  • Enzymatic detergent, rigid biohazardous-labeled bin and PPE are available for contaminated instrument storage until delivered to SPD.

  • No clean supplies or items to be stored in soiled utility rooms

  • All biohazard containers must be clearly labeled and covered with a lid

  • No other non-compliant findings.

Other

  • Was any Service Recovery required? If yes, please explain:

  • Please share any Staff Recognition:

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.