Audit

ENVIRONMENT OF CARE

No items stored under sinks?

Equipment / Furniture:
* No broken equipment or furniture stored on the patient care units.
* Coverings are intact - no rips or repairs needed.

Hazardous chemicals and flammable agents are labeled and stored properly.

Eyewash stations: not expired.

Refrigerators: Contain only those items designed for that refrigerator (specimen, medications or patient food)

Refrigerators: If manually monitored, logs are complete. Both manual and temp track-documentation is present for actions taken to correct out of range temps.

Fluid warmers: Set to maintain temp of 104. Necessary logs completed including actions taken to out of range temperature readings.

Electrical safety: Use of hospital grade power strips, plugs & receptacles in good condition.

No outer shipping carton boxes in patient care areas.

No expired items.

Preventative Maintenance:
* Equipment checked with up to date bio-med sticker.

EMERGENCY PREPAREDNESS

Can staff locate medical gas zone shutoff valves.

INFORMATION MANAGEMENT

Confidential Patient Information:
Cannot be overheard or seen by unauthorized persons:
* Computer terminals signed off when not in use.
* Patient information is not discussed in public areas.
* Labels and PHI are obliterated before discarding in the trash.

LIFE SAFETY

Appropriate storage of boxes and pt care items:
* Not directly on floor.
* 18" clearance from sprinkler head.
* Boxes stored on shelves close to floor must have solid bottom and high enough to not incur water damage from mopping.
* Volume of combustible material is not stored in large quantity as to create a fire hazard.

Oxygen or other combustible compressed gas cylinders are stored properly:
* Secured in floor stand, carrier or secured to the wall by a mount. (not laying on the floor or against wall)
* Limited to 12 E-cylinders per smoke compartment.
* Limited to 4 large cylinders.

Fire exits and hallways are cleared:
* Egress corridors must have 8ft clearance.
* Equipment in corridors must be actively accessed to be in use.

Fire alarm pull stations, fire extinguishers, medical gas shutoff valves are not blocked.

Fire extinguishers have been inspected monthly.

Fire doors are not blocked or propped and when closed there is positive latching.

Exit signs are illuminated.

Evacuation route posted & current.

Everyone has ID badges and worn appropriately:
* Staff and Visitors

Ceiling tiles are in place, no cracks, holes, misaligned or visible stains.

Floors, ceilings, walls, and other surfaces intact and free from holes.

Nurse call lights working (if applicable).

STANDARD PERFORMANCE IMPROVEMENT

Are units quality improvement dashboards posted on unit.

Is unit's PI project data posted.

PROVISION OF CARE TREATMENT AND SERVICES

Are there any alarms sounding that staff is not attending to in a timely manner.

INFECTION PREVENTION

Food and drink in designated areas:
* None in patient care areas or procedure areas.

Hand Hygiene Products:
* No empty alcohol gel bottles
* No empty soap or paper towels
* No unapproved lotions

PPE:
* Readily available
* Clearly marked
* Worn correctly

Patient food & drinks: No expired items.

Biohazard Waste:
* Discard in Red Bags with a biohazard symbol
* Not overfilled

Soiled Linen: Properly stored and not overfilled.

Separation of clean vs. dirty supplies & equipment.

Patient care supplies:
* Not expired, damaged, soiled.

Linen and Linen Carts: Covered and carts have solid bottoms.

Sharps Waste:
* Placed in puncture resistant sharps container.
* Disposed of when 3/4 full or "full" indicator
* Mounted appropriately

General Cleanliness:
* Observe surfaces for high dust & residue -floors, med prep areas, pt rooms & bathrooms
* No blood or bodily fluids

Air vents: Clean

All items in PT care area that are not disposable are able to be wiped down.

Curtains, drapes clean.

MEDICATION MANAGEMENT

Medication areas are clean and uncluttered.

Area free of distractions.

Medication is appropriately labeled.
* Expiration dates, directions, etc..

All medications, needles and syringes are secured in locked cabinet or locked room or under constant surveillance.

Controlled substances stored to prevent diversion.

Medications & solutions not beyond expiration date.

Opened multi-dose vials dated with today's date and initialed. Exceptions: vaccinations, PPD, and insulin.

Code Carts:
* Locked and marked with then first drug to expire.
* Checked per policy.
* Include defibrillator check.
* Cart is clean.
* O2 tank is >1/2 full

Syringes are labeled when in use.

WAIVED TESTING / POINT OF CARE TESTING

Point of Care testing control solution labeled & dated.

DESCRIBE THE UNITS RESPONSE TO YOUR ARRIVAL

Greet the team with smiles and introductions.

Promptly deliver materials required for review to the tracer team.

Any additional comments regarding positive or suboptimal issues observed during the tracer.

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.