Information
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Department(s)
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Conducted on
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Prepared by
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Personnel involved
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Staff & agency wear badges?
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Staff know how to handle a disruptive patient or visitor?
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Medication carts/drawers are locked when unattended?
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There are no unsecure medications at bedside or on top of carts?
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Staff personal items are stored appropriately (i.e. no purses, backpacks in public areas, nurses station)?
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Storage cabinets closed when not in use?
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Patient information is not in public view?
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Sensitive areas are secure:
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Pharmacy
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Medical Records
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Medication room(s)
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Storage/supply room(s)
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HR/Employee Health files
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Electrical/Mechanical rooms & panels
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Additional Comments
