Audit

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SAFETY MANAGEMENT/EMERGENCY MANAGEMENT/FIRE MANAGEMENT

Red S.T.E.P manual posted for review by staff?
Responsible for correction: Department

Exit corridors, exits and smoke/fire barrier door unobstructed?
Responsible for correction: Department

Are corridors, exits and smoke/fire barrier doors unobstructed?
Responsible for correction: Department

Exit direction identified by a minimum of two lighted signs in corridors? Responsible for correction: Engineering

Are items temporarily staged in the corridor? Especially if they don't have wheels.
Responsible for correction: Department

Any doors found improperly held open by any means?
Responsible for correction: Department

Exit doors, soiled utility doors and smoke/fire containment doors close and latch properly?
Responsible for correction: Department and Engineering

Fire extinguishers unobstructed and within current monthly inspection date (one year)?
Responsible for correction: Department and Engineering

Are items temporarily stage in the corridor moved to one side only? Responsible for correction: Department

Are any items stored in the corridor? (Especially if they don't have wheels.) Responsible for correction: Department

Alarm pull stations marked and accessible?
Responsible for correction: Department and Engineering

Hazardous storage area is within guidelines? I.E. Chemicals properly labeled.
Responsible for correction: Department, Engineering, and EVS

Randomly selected staff members demonstrate proficiency in fire/safety, bomb threat, evacuation and oxygen shut-off procedures?
Responsible for correction: Department

Sprinkler heads and air vents are free of corrosion and dust?
Responsible for correction: Department, Engineering and EVS

Storage is no closer than 18 inches from sprinkler head/ceiling?
Responsible for correction: Department

No storage allowed on the floor or under the sink?
Responsible for correction: Department

All lighting is in working order, including emergency wall-mounted battery operated units?
Responsible for correction: Department and Engineering

Walking surfaces are free from debris, loose coverings and other trip hazards?
Responsible for correction: Department

Patient room furnishings or appointments free from defects? (Bed, rails, chairs, grab bars, etc.) Responsible for correction: Department

Nurse call devices operate in randomly chosen rooms? Responsible for correction: Department

Staff is aware of "RACE" and "PASS" procedures? Responsible for correction: Department

Staff is aware of the Telephone Number to report emergency situations or fire emergency? Responsible for correction: Department

Staff has knowledge of the EOC Committee and the Chairperson? Responsible for correction: Department

HAZARDOUS MATERIALS AND WASTE MANAGEMENT

Container for disposal of sharps available in area and less than 3/4 full? Responsible for correction: Department and EVS

Are bio-hazardous waste containers used correctly? Responsible for correction: Department

Are authorized containers/quantities of hazardous materials present and adequately stored? Responsible for correction: Department

MSDS match recorded chemical inventory list? Proper labeling of all containers? Responsible for correction: Department

Randomly chosen staff members demonstrate knowledge of hazardous materials handling and can locate appropriate MSDS and Right to Know policy? Responsible for correction: Department

Staff is proficient in spill recovery procedures? Responsible for correction: Department

Is a spill kit present in the area (if applicable)? Responsible for correction: Department

Are oxygen/compressed gases properly secured and in the correct transporting device? Responsible for correction: Department

MEDICAL EQUIPMENT MANAGEMENT AND MISCELLANEOUS INFORMATION

Any equipment stickers out of date? Responsible for correction: Department and Biomed

Any PM stickers missing? Responsible for correction: Department and Biomed

Any defibrillators tested or checked IAW current procedures or practice? Responsible for correction: Department and Biomen

Use of portable heaters and warming plates are prohibited? Responsible for correction: Department

Staff is aware of repair, replacement, reporting and medical intervention procedures involving any equipment used in their area? Responsible for correction: Department

UTILITY SYSTEMS MANAGEMENT AND ELECTRICAL SAFETY

Switches and plug receptacles are in good working order with protective plates in place? Responsible for correction: Engineering

Plugs and cords on approved electrical equipment in good repair? Responsible for correction: Department and Engineering

Is extension cord use limited to only hospital approved devices? Responsible for correction: Department

Are multi-plug strips properly mounted? Responsible for correction: Department, Engineering and IT

Electrical closets are free from dust accumulation or improperly stored items? Responsible for correction: Engineering and EVS

Staff has knowledge of and the location of "red" emergency outlets in their area? Responsible for correction: Department

Mechanical areas free of combustible storage and free of obstruction to access to electrical panels? Responsible for correction: Engineering

Lighting and other mechanical items functional and in working order? Responsible for correction: Engineering

HOUSEKEEPING ISSUES

Are high and horizontal surfaces clean? Responsible for correction: EVS

Any cleaning supplies or carts left unattended? Responsible for correction: EVS

Is the EVS closed locked? Responsible for correction: EVS

Are all cleaning supplies properly labeled? Responsible for correction: EVS

Any excessive trash or soiled linen anywhere? Responsible for correction: EVS

Clean around dumpster areas? All lids closed and in good condition? Responsible for correction: EVS

Clean Linen carts covered? Responsible for correction: EVS

Any storage on top of clean linen carts? Responsible for correction: EVS

Any signs of insects or rodents? Responsible for correction: Department and EVS

Any broken or stained ceiling tiles? Responsible for correction: Department and Engineering

All furniture or room fixtures are clean and in good repair? Responsible for correction: Department, Engineering and EVS

MISCELLANEOUS INFORMATION

REFRIGERATORS:

Are refrigerators clean inside and out? Responsible for correction: Department and EVS

Are refrigerator temperature posted? Responsible for correction: Department

MEDICATION CARTS:

Are medication carts locked and secured? Responsible for correction: Department and Pharmacy

Is the Medication Room door locked? Responsible for correction: Department and Pharmacy

SECURITY OF PERSONAL ITEMS:

Staff and/or patient valuables left out unsecured? Responsible for correction: Department

ID Badges are present on each staff member? Responsible for correction: Department

Is PPE readily available? Responsible for correction: Department

Was appropriate hand hygiene practice observed? Responsible for correction: Department

OTHER ITEMS AS NEEDED:

ANY OTHER ITEMS OBSERVED DURING ROUNDS:

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.