• Audit Title

  • Document No.

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

Physical Environment

  • Are ceiling tiles free of damage?

  • Is the area free of slip, trip, or fall hazards?

  • Are extension cords being used?<br>

  • Are electrical panels (in public access) closed and locked?

  • Are electrical outlets free of damaged?

  • Are appliances clean?

  • Is the area free of exposed electrical wires?

  • Are visitor waiting areas free of damage (chairs, tables, etc)?

  • Are electrical appliances and/or cords located away from water sources?

  • Comments:

Fire Safety & Egress

  • Are fire extinguishers unobstructed?

  • Are pull stations unobstructed?

  • Is the area free from portable heaters?

  • Do fire doors operate correctly?

  • Are sprinklers heads free from damage?

  • Are exit signs illuminated?

  • Are hallways clear of clutter? Allowable carts include: crash, chemo, isolation

  • Do exit doors open in the path of egress?

  • Are evacuation routes accurate?

  • Are stairs free from hazards? (railings secured, moisture free)

  • Are exits free from obstructions?

  • Are storage areas compliant with the 18" rule? (except against walls- can go to ceiling but not within 4" of sprinkler head)

  • Are storage areas accessible and orderly?

  • Are supplies stored off the floor to facilitate cleaning?

  • Comments:

Patient Safety

  • Does medical equipment have an accurate TriMedx sticker?

  • Are oxygen cylinders stored in a clean, dry location, separate from other flammable or combustible chemicals/materials?

  • Are oxygen cylinders transported in a manner to prevent them from falling?

  • Are medical gas shut off valves properly labeled? (label on pipe or behind pipe on wall, not on outside cover or wall)

  • Are medical gas valves accessible?

  • Are sharps containers less than full capacity?

  • Are hazardous containers appropriately labeled?

  • Are hazardous rooms, employee only rooms, etc, labeled so patients or visitors do not enter?

  • Are dirty and clean linens stored properly?

  • Comments:

Team Member Questions

  • Do staff members know how to access MSDS

  • Do staff members know evacuation routes?

  • Do staff members know how to report occupational injuries?

  • Do staff members know how to report adverse events?

  • Do staff members know reporting procedures for broken or malfunctioning equipment?

  • Do staff members know their role during a Code Red?

  • Do staff members know their role during a Code Black?

  • Do staff members know their role during a Code Green and Code Silver?

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.