• Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel


  • Are egress corridors kept clear. And passageways

  • In suites managed to allow adequate save for:

  • Patients and staff to walk safely?

  • Are floors clear and slip resistant finishes in place?

  • Carts, wheelchairs, equipment and beds to pass with adequate clearance?

Are medications and sharps secured and locked?

  • Are medications and sharps secured and locked?

  • Are medication rooms and anesthesia carts locked when unattended?

  • Are needles and syringes locked when not attended?


Are the means of egress corridors/exit doors:

  • Clearly and correctly marked for EXIT, including when fire doors are closed?

  • Are exit signs functional

  • Are egress corridors and exits clear of any obstructions/equipment?

  • In secure units, locked doors in the means of egress can be readily unlocked by staff at all times (e.g. Keys carried by staff, pin code or badge access

Are fire extinguishers:

  • Clearly marked for identification and installed at correct height (maximum of sixty inches)?

  • Are CO2 fire extinguishers in place for use in operating rooms?

  • Inspection tags current and safety seals in place?

  • Accessible with three foot clearances in all direction?

  • Within seventy five feet in any direction in the area?

Are the fire pull stations:

  • Accessible, with three foot clearance in all directions?

  • In good condition, free from tampering and glass bar in place where applicable?

Are combustible materials:

  • Stored in proper containers (32 gallons or less)

  • Kept to a minimum for daily use in department?

  • Properly labeled and identified?

  • Are alcohol-based hand rubs properly mounted from electrical devices?

Compressed gases and trash/linen chutes:

  • Are there less than12 E- tanks (300 cu. ft. Oxygen) stored in the smoke compartment?

  • Where compressed gas storage exceeds 300 cu. ft., is there a designated, protected storage room?

  • Full and empty O2 cylinders in storage are segregated and labeled?

  • Are all permanently out of service dumb waiters sealed?

  • Are all dumbwaiters that are in use kept locked at all times?

  • Are all linen/trash chutes kept locked at all times?

  • Are all linen/trash chutes sprinkled?

  • Transferring of liquid oxygen prohibited?

  • Are vertical shafts (HVAC, dumb waiter, linen, trash), properly rated and maintained?

Fire Building Systems, components and Safety Practices

  • Are all doors free from being propped, wedged or held open in any way?

  • Are all doorways clear to close properly?

  • Are fire doors labeled properly and free of paint?

  • Do fire and stairwell doors latch positively and maintain closure?

  • Are stairwells free of storage and penetrations?

  • Do door coordinators function properly where installed?

  • Are all doors physically in good condition to prevent the spread of smoke or fire?

  • Are rooms used as patient/resident sleeping rooms free of deadbolt locks?

  • Is there at least 18" clearance between storage and sprinkler heads?

  • Are escutcheons in place on sprinkler heads and are they clean and free of debris?

  • Do patient privacy curtains haven't least an 18" mesh top?

  • Is the area free from portable heaters and heating devices?<br><br><br>

  • Are furnishing and decorations fire rated?

  • Is the area free from any evidence of smoking in the area?

  • Facility to inspect several fire/smoke walls to ensure walls are maintained in accordance with Life Safety<br>.


Are the floors in hallways:

  • In good physical condition?

  • Clean and dry?

  • Free from trip/fall hazards?

  • Wet floor signs used properly?

  • Carpet free of wrinkles or tears?

  • Free from obstruction (wires/cords etc)?

  • Is the flooring in operating/procedure rooms free of tears, nicks, or gouges that may prevent proper disinfecting of the floor?

Are the walls:

  • Painted and in good physical condition? (Free of holes or water damage)

  • Clean and free of splatters and stains?

  • Free from exposed wiring of any kind?

  • Are electrical covers/plates in place and in good condition?

  • Door frames and walls free from chipped paint that may prevent proper disinfecting?

  • Ceramic tile walls free of broken and chipped tiles?

Are ceiling tiles:

  • In place and in good condition?

  • Free of dirt, mold, dust, and stains?

  • Free from evidence of water stains?

  • Intact, no broken, pieced tiles?

Infection Control Practices

  • Are all sharps containers less than 2/3 full?

  • Is clean linen covered?

  • Is the clean linen physically and clearly separated from dirty linen?

  • Are all medications dated and labeled?

  • Any outdated medications /supplies found?

  • Are refrigerators labeled to identify "Patient", "staff" and "medication" use?

  • Are all foods dated and labeled?

  • Are current temperature logs in place and readily available?

  • Are cardboard boxes off the floor, with no corrugated shipping containers present?

  • Is ther evidence of bloodborne pathogen precaution procedures in place? ( gloves, mask, gowns, separation of waste, etc.)

  • Is personal protective equipment readily available for use!

  • Are the cabinets under the sinks free of storage and clean supplies/equipment?

  • Are all sharps storage areas kept locked at all times?

  • Have all product recalls been corrected by department?

  • Are floors, fixtures, and equipment in clean condition?

  • Are patient rooms and bathrooms clean and suitable for patient care?

  • Are emergency showers and eye washes tested?


  • Are janitor closets and other rooms with chemicals secured and stored correctly? (flammables, corrosives, etc)<br><br>

  • Labeled correctly?<br>

  • Disposed of correctly? (Are there procedures for disposal?)

Material Safety Data Sheets

  • Can staff explain how obtain MSDS information?<br>

  • Can staff describe what information is listed on an MSDS sheet?<br>

  • Is there a chemical inventory available?<br>

  • Have the MSDS and inventory been updated within the past 12 months?

  • Does staff know where the master MSDS is located<br>

Medical waste:

  • Stored in properly labeled bags and containers?

  • Properly stored and disposed of?

  • Stored and segregated appropriately?

  • Are bio-hazardous waste bulk storage areas secured, except o essential personnel?<br>


  • Are the inspection tags current with date of next inspection?

  • Can staff describe how they know if equipment is safe for use?

  • Is clean equipment identified and stored properly?

  • Can staff describe training requirements for equipment?

  • Can staff explain emergency procedures for life-support equipment?

  • Are crash cart logs documented consistently?

  • Are medical equipment consumables (defib pads, etc. ) within expiration dates?

  • Are temperatures within range for blanket warmers(<130)?

  • Are temperatures within range for fluid warmers (<110)

  • Are sterilizer records on file for each load?<br>

  • Are Daily Air Removal Tests (DART) performed on sterilizers and do records show compliant test results?

  • Are daily biological tests performed on sterilizers and do records show compliant test results?

  • Are integrator tests on file for each flash load, and do records show compliant test results?

  • Are PM records for sterilizers current and is equipment in good condition?

  • List two (2) equipment inventory tag numbers and verify that equipment information is correct and inspections are currentl?


  • Clearly Marked by red covers and outlets?

  • Being used for critical equipment only?

Electrical panels and devices;

  • Are breakers in distribution panels labeled?

  • Are mechanical/electrical rooms or exposed distribution panels kept locked, except to essential personnel?

  • Are all covers free from damage and securely in place?

  • Are waiting rooms provided with tamper-resistant outlets?

  • Is the area free of extension cords and multi plug-in outlet strips?

Are medical gas zone and main valves:

  • Marked to identify the area served?

  • Are the valves accessible for immediate access?

  • Can staff describe who is authorized to shut off medical gases in the event of an emergency?

Are plumbing systems:

  • Drains capped? (cysto)

  • Autoclaves free of leaks from supply, drain, or splashing?

Temperature and humidity

  • Is temperature and humidity monitored in each OR and areas where anesthetic gases are administered?

  • Are temperatures maintained between 68 and 73 degrees?

  • Are relative humidity levels maintained between 35 and 60 percent?

  • Have appropriate actions documented when readings are outside of parameters?


  • Are all employees wearing identification badges in plain view?

  • Can staff explain the procedure to get help in the event of a security emergency?

  • Are security measures in place for the OR and can staff explain their role in providing security for patients?

  • Can staff explain their role in a CODE ADAM?

  • Are all roof accesses locked except to essential personnel?

  • Is the OR locked after normal business hours?


  • Is there a current copy of the EOC/Safety manual available?

  • Can staff explain their role in the various emergency management operations?

  • Is there a copy of the Emergency Operations Plan available?


Are Mechanical Rooms:

  • Secure, neat, and orderly?

  • Free of storage?

  • Do all doors have closures?

  • Do all doors positively latch?

Soiled Utility Rooms and Storage Rooms >50 Square Feet

  • Clean, neat, and orderly?

  • items stored greater and 18 inches from fire sprinklers, unless fixed shelving against the wall?

  • Rooms are constructed as hazardous areas (i.e. 1 hour fire rated or smoke resistive and sprinklered)?

  • Do doors to Hazardous Areas have automatic closers?

  • Do doors to corridors and rated rooms positively latch?


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