• Audit Title

  • Document No.

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel


  • Warning signs or barricades are placed when work creates a hazard (wet floor, maintenance work in ceiling)?

  • All furniture and equipment is in sound condition? (no chipped or torn surfaces- no leaky faucets)

  • All wall-mounted devices (lights, TV’s, pictures, signs, containers, handrails, etc.) are secure and not loose?

  • Area is without clutter

  • Quality Control logs for Refrigerators/Freezers, freezers, and warmers are complete and corrective actions documented as appropriate?


  • No evidence of daisy chains

  • Items are not stored within 36" of an electrical panel?

  • Electrical cords, plugs, plates and switches are in good repair?

  • Extension cords only used temporarily but not on a permanent everyday basis?

  • The underside of beds and counters are free of electrical “wire nests” where feet could be entangled?


  • Medications/medical supplies - have not passed expiration dates?

  • All syringes, basins, cups, containing medication or solutions are labeled with the name of the contents?

  • Supply area is clean?

  • Med Carts/Med Rooms are secured at all times?

  • Black boxes have been emptied and are not overflowing.

  • Samples are tracked per policy?

  • No boxes on the floor. All supplies 6 inched off the floor?

  • No items stored under the sink


  • Staff food is not stored in patient refrigerators?

  • Refrigerators/Freezers are clean, frost free, and labeled for type of storage with only those items present (no food and medication in the same refrigerator).

  • Refrigerators/Freezers contain thermometers and the refrigerator graphs are up-to-date? (thermometer should be located in the back)

  • No open or expired patient nourishment containers in refrigerator?

  • Ice machines are clean, no signs of deposits in tray or dispensing mechanism?

  • Anti-microbial soap and paper towels are available for hand washing?

  • Containers used for regulated or infectious waste are covered, leak proof, and clearly labeled as a biohazard?

  • Disposed sharps are in an approved container?

  • Sharps containers are secured in their holders, not accessible to residents and not more than three-fourths full?

  • Staff (including contracting physicians) perform hand hygiene?

  • Separation of clean and dirty?


  • Ceiling tiles clean and intact?

  • Floors free of dirt, dust and litter?

  • Ledges, walls and air vents free of dust?

  • Toilets and sinks secure and clean?

  • Privacy curtains clean and unsoiled?

  • Cove base is secured?


  • Chemicals are properly labeled and secured?

  • How can you access Material Safety Data Sheets (MSDS)?

  • PPE is available?

  • Material Safety Data Sheets stickers are intact on phones?

  • Eye wash is flushed and logged?

  • Acids and bases stored separately?

  • Fume hoods have been certified?


  • Can you explain P.A.S.S. and what it stand for?

  • Staff know where the fire extinguishers and pull stations located in your department?

  • Confidential shred bins are compliant with NFPA Code

  • Halls/Corridors uncluttered and accessible?

  • Smoke detectors with 36" clearance from air supply to return?

  • Are the sprinkler heads free of dust?

  • Fire extinguisher (s) recently serviced? (monthly)

  • Automatic fire doors free from obstacles and positively latch when activated? (Doorways should not be blocked or wedged.)

  • Eighteen-inch clearance from ceiling is maintained?

  • Are compressed gases stored in designated areas only and secured?

  • Are med gas valves labeled?

  • Are full and empty cylinders stored separately according to sign/labels?

  • All lights are working properly and flashlights with good batteries?

  • Flammable and hazardous materials properly stored and labeled?

  • Fire extinguishers and pull stations clear of obstructions?

  • Placement of Hand Sanitizer is not adjacent(with-in 6”) to a potential ignition source?

  • Egress path is clear of obstructions?

  • Soiled trash/linen carts do not exceed 32 gallons in a 64 sq. ft. area?


  • Staff know the number to call to initiate an emergency response?


  • Staff know how to notify Security in a non-emergency?

  • Employees, volunteers, students, contracted staff, physicians, contractors and venders wearing ID badges?


  • Staff know the procedures if a device/equipment does not work properly?

  • All medical equipment/devices has a current Bio-Medical sticker?

  • Equipment is clean?

  • Crash cart is locked, logs complete, oxygen is full?

  • Defibrillator is plugged in and charging?


  • Staff know what to do for a utility failure?

  • Staff know who is authorized to shut off medical gases?

  • Is correct air pressure maintained in critical environments? (Decontamination, soiled utility, scope rooms, etc.) per FGI 2010 guidelines.

OR specific

  • Hyperthermia cart is locked with log completed?

  • Staff know location of hyperthermia cart?

  • Sterilizer is clean and parameters are maintained?

  • Sterilizer has documented PM?

  • Sterilizer testing is up to date?

  • Temperature and humidity levels are checked daily. Temperature should not be lower than 68 and humidity cannot exceed 60%. Per FGI 2010 guidelines.

Mechanical areas

  • Floor is clean?

  • Power tools have guards in place?

  • PPE readily available?

  • 36" clearance maintained around electric panels?

  • Fall protection for areas above 6 feet high?

  • LOTO equipment readily available?

  • Isolation exhaust fans are labeled?


  • Preventive action is required?

  • Preventive Action Plan:

  • Corrective action is required?

  • Cause of nonconformity

  • Organizational corrective plan:

  • Person/position responsible for implementation do corrective action

  • Date for implementation of Plan

  • Determine actions needed by observing:

  • Results of. Actions taken:

  • Review effectiveness


  • Department/Unit Representative

  • Auditor

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.