Any Items not stored off the floor and at least 18” from plane of ceiling

Check for thermometers in refrigerators and/or manual log of temperatures daily and not missing any dates

Some patient and med refrigerators and freezers are monitored electronically

Patient and employee foods are in separate refrigerators

Assure all medications, reagents and blood tubes are not expired

All syringes with medication or saline are properly labeled

All patient foods stored in the refrigerator are labeled and dated

Patient care items are not stored under the sink

Only Regular insulin stored in med refrigerator, and not expired

Assure all AccuCheck strips and controls are dated and not expired

Remove any supplies resting directly on floor (pallet required)

Oxygen tanks are labeled and secured and stored appropriately

(Stored in approved holder with no more than 12 “E” cylinders in a room or 1 “H” and 2 “E” in the room. Never lay flat)

Electrical panels and medical gas panels are free form obstruction

patient care supplies stored under sinks

Clean utility room is clean with no storage on floor

No cardboard boxes stored in OR’s or patient care areas

Pill crushers are clean

Pressure differential between rooms appropriate when needed


Crash cart is locked, lock number recorded/emergency equipment log maintained

Medication room/medications secure (carts auto lock)

Patient charts secured – computer screens secured

IVF, syringes, needles are locked and secure, unless in visible area at all times

Anesthesia medication carts are locked when not in use

Medication refrigerators are locked/secured in a locked room or under constant surveillance

Check that there are no personal items such as backpacks and briefcases in OR suites

Hazardous Material/Waste

Findings and Comments

Corrective Action/Follow-up

Regulated medical waste is distinctly separated from normal waste

Eye wash stations operational and logs completed weekly

Managers know how to access MSDS sheets

Housekeeping closets are locked

Dirty utility rooms are accessible and biohazard waste container is accessible

Emergency Preparedness

Staff can locate Emergency and Disaster references easily

Life Safety

Fire equipment (e.g., extinguishers, pull stations, fire hoses) free from obstructions

Fire doors are not propped open (no visible door wedges)

Hallways/corridors are free from clutter and storage

Check stairwells that open to your area to assure no equipment is stored there

Staff are able to verbalize what to do in case of fire

doors propped open with door wedges

Medical Equipment

Spot check several pieces of medical equipment with inspection


Remove unused medical equipment from the hallways and relocate to the designated storage area

Spot-check stretchers, mattresses, patient chairs: assure mattresses in good repair and without tears or cracks or rust

No tape on equipment

High-touch surfaces are cleaned and disinfected with an EPA-registered disinfectant (i.e., BP machine, electronic thermometers, pulse ox, WOWS/stretchers/IV pumps/bedside commode, etc.)

The glucose meter is cleaned and disinfected after every use. Test strips and quality control vials are dated when opened and not used after manufacturer's expiration dates

Infection Control

Disposable gloves and other PPE located convenient to areas of use

Alcohol based hand rubs (ABHR) near point of use, in working order, not located over electrical outlets/switches and not expired. Soap dispensers and towels available near sinks

Patient Rooms appear clean and sanitary, free from clutter and visible debris

Dated supplies within expiration dates

Sharps containers less than ¾ full and located neat point of use

Clean equipment is stored in clean area, dirty equipment is designated soiled holding areas. (i.e. soiled utility rooms)

Area free from visible dust including fire sprinkler heads and vent grills

Overhead lights free from visible insects, dust and debris

Patient contact surfaces are disinfected between patients

Floor coverings appear to be well maintained in halls and public areas

Floor finish appears to be well maintained in patient rooms, visibility clean

Patient equipment cleaned and disinfected between each patient use

Refrigerator clean, maintained per policy

Ice machine exterior components visibly clean upon inspection

Soiled linen is located in contained hampers/bags and not overfilled

Eye wash stations visibly clean, maintained per policy

EVS closets clean, orderly. Floor sink cleaned on regular basis

Injection Practices

Open vials of medications / sterile solutions are dated & stored properly

Multi-dose vials are dated when open and labeled if use for a single patient

There are no expired medications/items/supplies

Single Patient Use Practices

Single dose (single-use) medication vials are used for only one patient (A “No” response must be cited in relation to 42 CFR 416.48(a)

Manufactured pre-filled syringes are used for only one patient

Bags of IV solution are used for only one patient

Bags of IV solution are labeled with the patient's full name, MR#, date and time. IV site labeled date/time of insertion

Medication administration IV tubing is labeled with date for change



Compliance Rate = Total # items compliant X 100

Additional Pictures / Comments

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.