Title Page
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Site conducted
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Conducted on
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Prepared by
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Location
Name of Auditor
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ID Number
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Untitled Page
CRITERIA
PATIENT CONFIDENTIALITY AND SAFETY
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No patient personal information in public. No opened EMR is left unattended
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All patients wear clear ID band with 2 identifiers
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All lines are traced and tubings are dated, valid and labeled (Line Reconciliation)
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Adult and pediatric patients identified at moderate risk and above are to wear a red patient identification band with 'Risk for Fall" written, 'Falls" alert attached to their file, and a sign placed by their bed, cot, and/or room door
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Side rails are up and bed in the lowest level
INFECTION CONTROL
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Regular and infectious waste are disposed properly. Garbage bin is not overfilled
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Sharp containers are not more than 3/4 full
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Mounted sharp containers are at/or below eye level
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Approved WHO poster for hand hygiene is visible in all sink, soap and alcohol hand rub dispensers
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Patient' s door has correct transmission-based precaution signage as required
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Monitoring of negative pressure room is done on a daily basis if occupied by a patient / weekly for not occupied rooms
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Used CSSD items are kept in correct place
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Treatment trolleys are clean and tidy
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Used linens and hamper bags are stored in soiled utility room. Infected linens are inside the red hamper bag
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Staff perform proper hand hygiene before and after visiting patients
FACILITIES
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Patient rooms are clean and tidy
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Patient bathrooms have nonslip surface and there is access from outside if locked inside
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No obstacles in the way of emergency exit and fire extinguisher
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Fire exits are clearly marked with illuminated exit sign
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Daily equipment checklist: Availability, Functionality and Cleanliness - is done every shift<br>
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A minimum/maximum level for linen requirement per unit is established and should be adhered to
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Fresh/clean linen is to be stored separately from dirty/used linen
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Clean linen store is to be secured and preferably locked
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Problems with amounts, availability or quality of linens are to be documented on a Linen Problem Log and followedup
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Daily linen monitoring sheet is updated and completed
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Staff lounge is clean and tidy. Top of lockers are clear from dusts and clutter
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Food inside the refrigerator is labelled
STOCK ROOM
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Minimum, maximum and critical levels of all supplies/stock are available
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List of required supplies/stock by description, item code, and amount available
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Supplies/stock stored in an organized and accessible manner that permits easy identification
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Each supply/stock item is to be labeled with its name, code, and required minimum and maximum level
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Sterile items are stored separately from nonsterile items
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No unnecessary boxes and wrappings stored in the stock room/no boxes on the floor
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All items/shelves are at least 50 cm away from the ceiling
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Heat/smoke detector and sprinkler present
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Individual items are arranged into separate labeled containers or shelf space
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Heavy items are placed at waist height
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Fluids are stored in lower shelves – temperature and humidity is regularly monitored and recorded in the temperature monitoring log sheet
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Supplies/stocks are rotated so that the most recently received items and near expiry items shall be utilized
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Items that have an expiry date of fewer than 3 months are returned to the warehouse
MSDS
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MSDS folder is available in the area
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MSDS list is updated annually (inventory list) and MSDS sheets are updated in the folder
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Proper labeling of items according to hazard rating classification (Diamond sticker)
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Contact number of Safety Officer is available for any suspected or witnessed release of a hazardous material to the environment
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Spill kit is available and not expired