Title Page

  • Conducted on

  • Prepared by

  • Campus Location

AHS Rounds

EOC Exits & Egress; Medication Room

  • All Staff must wear name badges with photo ID visible above waist

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

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

  • Fire rated doors must latch & close properly

  • No flammable items on fire rated doors

  • Medical gas shutoff valves, fire extinguishers, and alarm pull stations are not blocked.

  • Nothing stored under sink throughout unit

  • No doorstops used or doors propped open

  • No overfilled sharps containers throughout the unit (replace when ¾ full)

  • Patient Health Information (PHI) protected from public view

  • No food or beverages in patient care areas or nurse’s stations

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

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

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

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

  • Med Room: Med Room locked with access for authorized personnel only

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

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

  • Medication refrigerator and freezer temperatures logged and documented daily

  • Med Room check for expired medications and supplies

Waived Testing and Infection Control Practices:

  • All employees wearing universal COVID mask, covering mouth and nose

  • All employees have been screened according to COVID employee screening guidelines (wearing current date's sticker)

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

  • Waived Testing: Glucometer cleaned. Controls and Strips dated w/date opened/expiration date: Toss after 90 days

  • Hand gel stocked in all dispensers

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

  • No open Sani-Cloth containers

  • Hand hygiene performed when staff entering & exiting patient rooms

EVS, Clean and Soiled Utility Rooms ( C and S)

  • EVS/Housekeeping closet, clean and soiled utility doors are closed and secured (not propped open)

  • C: Linen carts must be covered and have solid bottoms throughout the unit

  • C: No supplies stored on the floor. Must be on pallets or wire shelving with solid bottom

  • C: No corrugated shipping boxes. Remove immediately

  • C: O2 tanks are stored upright in the holder. Full (>2000PSI) and empty O2 tanks are separated with signage

  • C: Check for expired medications and or supplies throughout the unit

  • C & S: No supplies stored within 18 inches from the bottom of the sprinkler head

  • S: No clean supplies or clean equipment to be stored in the soiled utility room

  • S: No storage of patient personal belongings

  • S: Floors are clutter free, allowing access to sink, hopper, and door

  • S: Approved enzymatic gel/ instrument cleaning supplies in room (if applicable)

  • S: Instruments in red biohazard bins are wet (sprayed) and in open position

  • S: Hazardous waste containers are closed/covered and labeled with biohazard sticker on lid and 3 sides of container

  • S: Equipment requiring cleaning or services must be clearly marked

Procedure Room and Areas

  • Time outs are performed for all required invasive procedures; total team participation with active pause

  • Medications are labeled when removed from the original manufacturer container

  • Patient Consent, completed H&P on file in the medical record prior to start of procedure

  • Required PPE is worn by all staff in procedure rooms/ ORs

  • All PPE except head coverings (e.g. bonnets, skull caps) removed when going outside procedural areas – no booties in hall; gloves are removed upon exit

  • General cleanliness; no extra linen / supplies out in the open

  • All syringes/meds/specimens must be secured and attended by authorized individuals

  • Pre Anesthesia documentation complete include ASA level and/or appropriate assessment

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.