• Document No.

  • Unit / Area:

  • Conducted on

  • Prepared by

  • Personnel

General Safety

General Safety Items:

  • Egress routes / corridors are clear and uncluttered?

  • Ensure staff is aware of panic button in nursing station?

  • WOWS / COWS medical equipment in egress / routes corridors are moved in 30 minutes?

  • Oxygen is stored appropriately (no more than 12 cylinders per smoke compartment) and cylinders are secured in holders and racks?

  • Nothing is stored within 18 inches of fire sprinklers in all areas?

  • Electrical outlets are visibly functional (no blackened plugs, lacking covers, loose or broken covers)?

  • Nothing is stored / parked directly in front of electrical / medical gas panels?

  • Staff knows (RACE) and PASS for fire extinguishers?

  • Staff knows emergency code blue extension (ext. 2333)

  • Staff is aware of codes that may be called (Red, Blue, Yellow, Pink and Black)

  • Staff is clear on their roles if a code is called and how to report a safety and / or emergency concerns/issues (ext 6911)

  • Nonfunctioning medical equipment is reported to Biomed immediately

  • Red bag trash is labeled appropriately, emptied regularly and needle boxes are less than 3/4 full

  • Hazardous materials have MSDS available on MSDS online and are stored/labeled appropriately?

  • Doors are not propped open or locks disabled anywhere for any reason

  • Ceiling tiles do not have stains, cracks, missing or broken

  • Staff were not eating or drinking in designated work areas

  • Comments:

Staff Narrative

Staff Narrative

  • What was working well today?

  • Are there any specific areas that need attention and why?

  • Are there any areas that should be recognized and what makes it notable?

  • Did you receive any negative feedback from patients, visitors, employees or physicians? If so, how do you plan to address and resolve the issues?

  • Is there anything we can do better?

Quarterly Focus

  • Was a specific task being performed (I.e. codes, Biomed repairs, etc)?

  • Did you identify anything that could affect the patient experience (I.e. medical equipment, outlets, red boxes, eating / drinking in work areas, etc.)?

  • Do you have any recommendations to improve the issues you identified?

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.