Audit

Housekeeping

High Reach Horizontal Surfaces are Clean 07.00.00

Surfaces are uncluttered and free of dust 07.00.00

Sprinkler Heads and Smoke detectors are free of dust and dirt. 11.04.06

Vents are free of dust and dirt. 07.00.00

Environmental Service carts not left unattended in Corridors. (Hospital Only)

Empty pop cans are not stored with patient care items. 07.03.07

Vending Machines are clean. 07.03.03

Wheels on carts are clean and free of dust and/or debris 07.00.00

ENVIRONMENTAL

Doors are not propped open. 11.04.05

Ceiling tiles are not stained, missing, or broken. 07.03.04

In sprinkled areas, supplies are stored 18 inches from ceiling. 11.04.06

Items are not stored within 30" directly in front of electrical panels. 1910.303/NFPA

Elevator Areas, Corridors, and Egress routes are free of equipment and any obstructions. 11.04.08

Furniture and Equipment removed if in poor condition (cracked, torn, broken, ect) and Maintenance notified. 07.00.00

PATIENT CONFIDENTIALITY

Computers are " Logged-off" when staff is not present.

Monitor Screens are oriented to protect patient confidential information.

Doors are locked to Medical record Storage areas. 10.00.04

Check all areas for HIPPAA violations (check trash cans, patient charts, test results, etc)

WORK PRACTICES

Staff, Doctors, Volunteers, and Students wearing ID at all times. 04.00.13

Proper Lifting Equipment available if needed. (Hospital Only)

Only Hospital approved hand lotion is available and in use.

LIFE SAFETY

Exit Signs clearly visible and working properly. NFPA 99

Fire doors and Emergency exits are unobstructed. Fire extinguishes and fire alarm pull stations and accessible (Not Blocked). 11.04.05/11.04.06

Staff is familiar with the location of fire extinguishers, medical gas shut-off valves (if applicable), fire alarm pull stations (if applicable) and notification procedures if there was an Emergency situation in the department. 11.00.02/11.07.01

STORAGE ISSUES

Items are not left unattended in corridors. 11.04.08

Items are not being stored on the floor. 11.04.08

No items (clean or sterile) stored under sinks. In non-patient areas, no paper items or non-labeled chemicals are stored under sinks. 07.02.04/07.02.07

Items are not to be stored within the splash zone of the sink (3'). 07.03.05

All linen items are stored properly-clean with clean, and dirty with dirty, and covered. 07.04.01/07.04.03

HAZARDOUS MATERIALS AND WASTE

Staff knows how to access MSDS information. 11.05.04

Tank of Compressed gases (oxygen) are properly stored, not left on empty wheelchairs, stretchers, or left in corridors. Only 1 bottle is allowed to be stored at the Nurse's Station. 1910.253/NFPA 99

All Biohazard containers are handled and labeled appropriately. 49 CFR

In areas using hazardous materials, emergency phone numbers are posted in the case of a chemical spill. 1910.120

All chemicals properly labeled and stored. 11.05.04

If eyewash stations are in the department, they are inspected and operated weekly to verify working order, and are unobstructed. ANSI Z358.1

Biohazards are disposed of in the proper containers-sharps, bio-bags, etc. 07.03.07/49 CFR 171/1910.1030

If a department uses a high level disinfectant for equipment sterilization (Cidex OPA), daily checks are completed and logged.

Food and Beverages are not stored or consumed in areas where chemicals are used or stored. 1910.120

INFECTION PREVENTION

Staff food/drink items are not in patient care areas (i.e. nurses stations). Staff do not apply lip products in patient areas. 07.01.10

Staff belongings are not stored in patient care areas.

Sterile/Clean equipment stored (6" from outside wall, 18" from the ceiling, and 6" from the floor) and rotated appropriately. 07.02.04/07.02.07

Sterile/Clean equipment not stored together with "dirty" utility items or in traffic areas. 07.02.04/07.02.07

Specimens are transported correctly (gloves are used when transporting to soiled utility room, specimens are in bio-hazard whenexiting the department). 1910.1030

Linen is covered during transport. 07.04.01/07.04.03

All clean linen carts are covered, or in an enclosed room. All dirty linen hamper lids are closed. 07.04.01/07.04.03

Areas under sinks show no evidence of mold/mildew growth.

Opened and outdated nourishments are removed from refrigerators. 07.02.07

Refrigerators and freezers for specimens are properly labeled with a biohazard label. 07.03.07

Refrigerated specimens are not stored in with refrigerated food items, and patient food is not stored with staff food in refrigerators. 07.00.00/07.03.07

Refrigerators are periodically cleaned inside and out.

Dirty Equipment is cleaned before being sent to CPD.

PPE is available and used properly. 07.01.01/OSHA 1910.1030

Alcohol based hand hygiene products are available for staff. 07.03.05

Soap and hand towels are available at each hand washing sink. 07.03.05

Sterile supplies are not expired and are labeled with a lot number. 07.02.07

No evidence of pests or entranceways for pests. 07.05.01

No evidence of poisons used to exterminate pests. 07.05.02

Brushes used for cleaning medical equipment evaluated and cleaned daily.

Upon opening an in-house processed sterile tray or set, the chemical indicators are validated. 07.02.04

MEDICAL EQUIPMENT

Preventive maintenance stickers are up-to-date. 11.08.06

ERT carts are checked daily ( seals are not broken).

ERT Carts are plugged into red outlets. 11.08.04

Emergency equipment/supplies (ambu bag, Ephinephrine, Benadryl, airways) are monitored monthly for expiration.

Blanket warmer temperature set at 130 degree F (if not automatically monitored)

IV solutions in volumes of 150 ml or greater are warmed to 104 degree F for no longer than 14 days

Pour bottle solutions are warmed to 150 degree F for no longer than 3 days

All comfort bath warmers are set to 125 degree F +5 degrees

Non-functioning electrical and patient care equipment removed from service and Clinical Engineering notified

Your HEPA hoods are present, labeled correctly for your department, and plugged in. The hood itself is free from damage or tears.

ELECTRICAL

Extension cords are not in use (power strips are permitted). 1910.303/1910.334/NFPA 99 & 70E

Electrical equipment (including outlets) are in good repair and are secure. 1910.305/NFPA 70E

MEDICATION SAFETY

Medications are secure. 25.01.03

Medications are not outdated. 07.00.00

Medications are properly labeled with the name of the medication, manufacturer, concentration, lot number, and expiration date in month/day/year format. 25.01.07

Multi-dose vials are labeled with the initials of person who opened the vial, and the expiration date (28 days after opening). 07.00.00

Pill crushers are clean.

Medication refrigerator temperature logs current?

RADIATION SAFETY ISSUES

Staff members are wearing appropriate badges (radiation dosimeter). 19.00.01

Appropriate shielding is available for patients, staff and visitors. 19.00.01

Rooms housing radiation sources are labeled.

Lead aprons and gloves are worn when necessary. 19.00.01

Lead apron checks are completed annually. 19.00.01

PATIENT CARE AND NURSING (HOSPITAL ONLY)

All audible alarms are set on patient care equipment.

Emergency pull cords are 4 inches from the floor and free hanging.

STAFF INTERVIEWS (Instructions: Interview 3 staff members(from different shifts if possible) with the below questions)

How can you access an MSDS sheet?

Do you know who the Safety Officer is and how to contact him/her?

How are employees notified if our disaster plans are activated?

Where are the nearest fire extinguishers and AND fire alarm pull station located?

How is the fire code announced overhead?

Where is the medical gas shutoff valve located?

TOTAL SCORE
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.