Audit

SAFETY MANAGEMENT

Housekeeping closets are locked (EC.02.01.01 EP8)

Soiled utility rooms are locked (EC.02.01.01 EP8)

Clean utility rooms are locked (EC.02.01.01 EP8)

Oxygen storage rooms are locked (EC.02.01.01 EP8)

Medication rooms are locked (EC.02.01.01 EP8)

Utility closets are locked (EC.02.01.01 EP8)

Handrails are firmly attached to the walls including in bathrooms and in the hallways (EC.02.01.01 EP3)

Patient call light cords are no more than 6" from the floor (patient rooms and in restrooms)

Are there any slip and fall hazards in the department? (EC.02.01.01 EP3)

Staff are able to properly describe the process on how to handle an injury of a patient

Staff are able to properly describe the process on how to handle an injury of a visitor

Staff are able to properly describe the process on how to handle an injury of an employee

Staff know where lifting equipment is located and how to properly use it (gait belts, hoyer lifts, slide boards)

SECURITY MANAGEMENT

All staff members are wearing hospital identification badges (EC.02.01.01 EP7)

The department has flashlights that work properly and are stored in an easily accessible location. (EC.02.02.09 EP2)

Clean sharps are secured and locked in cabinets, carts, or locked containers (EC.02.01.01 EP3)

Doors that should be locked are locked to control access into the department from patients and visitors (EC.02.01.01 EP3)

Childproof protective outlet covers are located in outlets in lobbies, hallways, and public gathering points

Medical records cannot be seen from the "public's" point of view at the workstations/nurse's station

Signage in your department is in good condition and reflects the current operational practices for your unit (LD.03.04.01 EP3)

Staff's belongings and personal items are not easily accessible by patients and visitors (EC.02.01.01 EP3)

Ask staff if they feel safe working at Allegiance Health. How could they feel more safe?

Panic alarms are present in high risk areas (ED/ Behavioral Health) and work properly

HAZARDOUS MATERIALS AND WASTE MANAGEMENT

Hazardous chemicals in your department are stored appropriately (EC.02.02.01 EP5)

Medical waste containers are not full and labeled with the date installed and expired (NOT MORE THAN 90 DAYS) (EC.02.02.01 EP12)

BioHazard Waste (sharps) containers are not over filled. If they are please change these appropriately (IC.02.01.01 EP1)

Eyewash stations and/or flush bottles are working properly and not expiered

Nothing is stored under sinks

Verify that the chemicals stored/ used in the department are listed on the eBinder

Chemical storage containers and locations are labeled/ identified properly

SDS signage is located within this unit and reflects the current information (name and contact info)

Staff know how to access MSDS online (eBinder)

MEDICAL EQUIPMENT MANAGEMENT

Biomedical inspection labels are placed on equipment inspected by BioMed and they are not expired

Refrigerators are labeled for their use (ie: patient, staff, medications)

Temperatures in refrigerators are being documents according to department policies and maintain the proper temperature (36-41F OR 2-5C)

Equipment that emits heat is labeled as such (ie: coffee pots, blanket warmers, fluid warmers)

Blanket warmer temperatures are set within the appropriate range

Staff are able to properly describe the process on how to handle defective medical equipment

INFECTION CONTROL

Staff's food and beverages are not present in patient care areas (LD.04.01.01 EP2)

Personal Protective Equipment (PPE) is adequately stocked and readily available; in good condition; and appropriate for the department (IC.01.02.01 EP3)

Does the isolation cart contain ample supplies (i.e., gowns, signs, masks, gloves)?

Linen carts are covered with impervious covering (IC.01.02.01 EP4)

Metal storage racks have a protective covering (plastic) on the bottom shelf to protect from splash up. (IC.01.02.01 EP4)

Soiled linen bags are not overfilled (EC.02.01.01 EP3)

Trash bags are not overfilled (EC.02.01.01 EP3)

No items are stored under sinks (LD.04.01.01 EP2)

Storage is at least 6" from the floor and no boxes are stored on the floor (IC.01.02.01 EP3)

Areas are clean, sanitary, and free from reoccurring offensive odors. These include lighting, vents, surfaces, walls, ceilings, and equipment (EC.02.06.01 EP20)

Paper towels are placed in the dispenser not placed on the countertops (NPSG.07.01.01 EP1)

Alcohol based hand rubs are not empty and dispensing properly (IC.01.02.01 EP3)

There are no rips or tears on vinyl covered patient equipment or chairs. (Stretchers, treatment table coverings, ect) (EC.02.06.01 EP26)

Verify pressure relationships (Negative/ Positive)
Soiled Utility Rooms/ Decontamination Rooms= Negative Pressure
Clean Utility Rooms/ Operating Rooms/ Sterile Areas= Positive Pressure
Patient Care Rooms= Positive or Negative

Graytop and Clorox wipes are not outdated

Stocked medical supplies, food, and medications are not outdated

Areas are clean, sanitary, and clean from reoccurring offensive odors. This includes lights, vents, horizontal surfaces, ceiling tiles, walls, and equipment.

Can staff explain how a patient is placed in isolation?

Staff are able to properly describe the dwell times for our cleaning wipes
Graytop- 3 Minutes
Clorox Wipes- 30 seconds- 3 Minutes

Can staff state the number one way to help prevent the spread of infection? (Wash in/ Wash out)

FIRE SAFETY MANAGEMENT

Hallways are free from all obstructions. This does NOT include crash carts, isolation carts, and equipment in use (this means accessed at least every 30 minutes or often) (LS.02.01.20 EP13)

Stored items are more than 18" from the bottom of the ceiling in any room (LS.02.01.35 EP6)

Sprinklers and smoke detectors look free from dust (LS.02.01.35 EP5)

Fire extinguishers and pull stations are not blocked at all times (LS.02.01.35 EP8)

Fire extinguishers have been inspected this month (Look at the backside of the tag) (EC.02.03.05 EP15)

Emergency Exit signs are clearly visible and working properly (evenly illuminated) (LS.02.01.20 EP13)

Emergency Evacuation Signage/ Maps are posted and reflect the proper evacuation routes

Fire doors are not blocked from shutting and latching properly (LS.02.01.30 EP11)

Doors are not wedged open (LS.03.01.20 EP8)

Medical gas shutoff valves are labeled and clear of obstructions (EC.02.05.9 EP3)

Flammable decorations like natural Christmas trees are not present in the hospital at any time (LS.02.01.70 EP1)

Space heaters are not present at anytime in patient sleeping areas and only radiant heat panels are allowed in all other areas
If any heaters other than radiant heat panels are found during rounding, remove them immediately

Staff can describe the proper process for responding to a fire (RACE) and using a fire extinguisher (PASS)
RACE:
Rescue anyone in immediate danger
Activate the alarm pull station/ call 9-911
Contain the fire by clearing hallways of obstructions and closing doors and windows
Extinguish the fire if able and if appropriate evacuate

PASS:
Pull the pin
Aim the nozzle at the base of the fire
Squeeze the levers together
Sweep the nozzle at the base of the fire SLOWLY

Oxygen tanks are stored properly (no more than 12 tanks (full or empty) stored in an approved location. The storage racks are labeled correctly

UTILITY SYSTEMS MANAGEMENT

Sinks, showers, toilets, and water lines are in good repair (not leaking and working appropriately) (EC.02.06.01 EP1)

Extension cords are not used in the department (EC.02.03.01 EP1)

Electrical outlets are not damaged or loose and have covers. This also includes switches, and network connections (EC.02.03.01 EP1)

Electrical panels are labeled as such and locked (locked in public areas) (EC.02.05.01 EP8)

Internal walls, doors, ceilings, cabinetry, and floors are in good condition

ABOVE THE CEILING

Penetrations are filled with fire approved chalking

Sprinkler lines do not have anything hung from, draped over, or tied too them or their support brackets

Electrical junction boxes have covers on them

Nothing is stored above the ceiling (basins, covers, debris)

OUTDOOR SAFETY ROUNDING

Outdoor signage is visible and evenly illuminated

Outdoor lighting is working properly and illuminating appropriate areas

ADA accessible ramps are clear from obstructions

Parking lots are in good repair (no potholes, large cracks, visible lines, curbs are intact)

During winter months parking lots, sidewalks, steps, and curbs are free from snow and ice

Emergency Exits are free from any external hazards (snow/ice (falling), shrubs, rocks)

Fire Department Connections (FDC) are visible and not blocked by shrubs, vehicles, or snow/ice

External walls, doors, windows, etc. are in good condition

NURSING SECTION (TO ONLY BE COMPLETED BY A NURSE ON THE ROUNDING TEAM)

Can staff state any one of the National Patient Safety Goals?

Can staff give an example of a “never event”? (Surgery wrong body part, Infant discharge to wrong person, Patient death with med. error)

Staff knows patient identifiers used when taking blood samples, giving medications or blood products?

Staff labels blood and other specimens in the presence of the patient?

Staff knows the process for scanning medications? (Scans patient ID Band then Meds with bar code scanner prior to giving meds)

Staff knows how long glucometer solution is good after opening? (90 days, labeled with exp. date)

Does staff know that patients at risk for suicide require continuous 1:1 observation until physician orders otherwise?

If restraints were used, is the patient being monitored appropriately according to the type of restraint used? ( Review doc flow sheet in the patient's chart)

Staff knows the proper way to receive verbal or phone orders?
( Enter into the patient's chart and read back)

Does staff know how to adjust the temperature in the refrigerator/warmer?

Was the consent to treat signed by the patient or representative?

Can the nurse identify the patients’ primary language?

Does the nurse know if the patient has an advanced directive?

Staff completes the pre procedure checklist in the patient's chart for all patients undergoing an invasive procedure?

Does the nursing care plan contain all required elements based on the initial assessment? (pain/abuse/skin/VTE/smoking/falls, etc.)

Staff knows the process used to communicate with other caregivers when providing the status of a patient or transfer of care? (SBAR)

Does staff know how long they must remain at the bedside immediately after the administration of a blood transfusion? (15 minutes)

Does staff know where to find a list of patients’ rights and responsibilities?

Does staff know what programs or methods are available for patients and families to report concerns related to care, treatment, services, and patient safety issues? (Patient Advocate, Nursing Managers/Charge nurse, and follow chain-of command, CMS & TJC Hotlines)

Does staff know what programs or methods are available for staff to report concerns related to care, treatment, services, and patient safety issues? (Follow chain of command)

Does the staff know what interpretive services we offer and what the process is to provide on off hours?

Is the current month Defib Log the ONLY log in the book? (current log in book only)

The monthly log is free from any missing checks? (All required signatures are present on the log)

Can the nurse identify how each patient is assessed for learning needs?

Can the nurse state the goals for their patient?

PHARMACY SECTION (TO ONLY BE COMPLETED BY A PHARMACY REPRESENTATIVE ON THE ROUNDING TEAM)

Does staff know the proper procedure for checking the crash cart?

All medications are secured (MM.03.01.01 EP3)

Are insulin & multi-dose vials labeled with the expiration date?

Are fluids in refrigerator/warmer labeled with the expiration date?

Is the record free from unacceptable abbreviations?

Do all PRN medication orders include indications?

Is the record free of any therapeutic duplication of PRN orders?

Does the staff know the process for informing a patient of the med. reconciliation upon discharge?

Can staff identify high alert drugs or look alike/sound alike drugs?

Does staff know how to report medication errors?

Can staff identify sources of drug information?

Does staff know what safeguards are in place when treating a patient on anticoagulants?

What is the current process if a physician allows a patient to take their own medication from home? (3 requirements: medication is non-formulary, the pharmacy has confirmed the medication and affixed a supplemental label to it, and the patient’s own medication should be stored in the medication room.)

Does staff know who educates patients on Warfarin and dietary interactions? (Dieticians and Nurses)

Does staff know what lab value is followed for a patient on Warfarin? (PT/INR)

Can the staff describe the process for labeling medications on and off a sterile field?

Are opened irrigation bottles labeled with an expiration date?

Is the medication prep area including the pill crusher/splitter clean and clutter free?

Does staff know what medications require double check? (Heparin, Infusion, Insulin, PCA pump, Chemo)

Does staff know the requirements of the double check? (Visibly verify order, Dose, Product, Pump programming with another nurse)

Can staff properly explain what meds need to be disposed of in the blue/black pharmacy containers?

EMERGENCY MANAGEMENT

Does staff know where to access emergency management policies? (IDA and Safety Manual)?

Does staff know what to do during severe weather (thunderstorm/ tornado)?

Does staff know what to do during a Code Pink (infant/ child abduction)?

Does staff know what to do during a Code Yellow (bomb threat)?

Does staff know what to do when they discover a patient is missing?

Does staff know what to do during a Code Silver (active shooter)? RUN HIDE FIGHT

Does HOSPITAL staff know the universal number to call to activate a code? (ext. 7000)

MISCELLANEOUS

Can staff describe hospital’s Mission and Vision Statements?

Can staff describe the proper process to dispose of Protected Health Information (PHI)

Any other concerns for your unit or area of inspection?

Please add and additional photos during this audit that are of a concern but do not fit into any of the above categories.
END OF SURVEY
Department Manager or Designee Representative
Environmental Services Department Representative
Nursing Representative
Pharmacy Representative
Plant Engineering Representative
Safety Department Representative
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.