• Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel


  • Physical hazards that would cause slip/trip/fall/puncture/cuts

  • Look at stair treads, floor tiles, carpeting, sink areas, ice machine areas, wall fixtures, etc.

  • Furnishings in good repair?

  • Furniture, wheelchairs, mattresses cannot have holes or tears. Tape not allowed

  • Clean items not stored in "Dirty" areas.

  • Dirty items not stored in "Clean" areas.

  • Grab bars and handrails securely mounted.

  • Place a work order to address if an issue is observed.

  • Equipment is clean.

  • Free of dust, dirt.

Patient Safety

  • Dirty linen not overfilled

  • Clean linen stored covered

  • Appliances for patient food clean. Temp checked. Safety label on toasters, microwaves, refrigerator.

Hazardous Material/Waste

  • Hazardous material secure?

  • Covers closed on all containers. Dirty utility door locked.

  • ESD closets locked at all times. Carts never left unattended.

  • Chemicals are stored in ESD closets and on carts. These items should be secured at all times. Carts should not be brought into patient rooms.

  • Needle boxes available/secure/not overfilled

  • Free standing containers must have cover closed when not in use.

  • No evidence of mixed waste streams. Regular trash, Regulated Medical Waste, Sharps should all be in proper receptacles.

  • Regular trash in wastebaskets. Regulated Medical Waste in red bags or bins. Sharps (including syringes without needles) once used are immediately disposed of into sharps containers.

  • Eye wash stations/showers unobstructed with weekly inspection records.

  • Able to easily walk up to or under without having to move anything. Weekly test for 5 seconds or until clear.

  • Gas cylinders secured-chained or in holders. No more then 6 full and 6 empty cylinders on one smoke compartment.

  • Each nursing unit is its own smoke compartment. Consider other patient care areas as one smoke compartment. O2 tanks with >500 psi in clean utility and <500 in dirty utility.

Fire Safety

  • Egress passages and exits are free of obstructions.

  • No carts, furniture, etc. are positioned so as to " narrow" the width of a doorway or easy passage through a hallway. "In Use" carts must be moved within 30 minutes.

  • Exit signs are illuminated.

  • Pull Stations are accessible.

  • Nothing on the floor directly in front of pull station.

  • Fire Extinguishers accessible and inspection tags up to date.

  • Medical Gas Valves and alarm panels labeled and accessible.

  • Sprinkler heads not obstructed. 18" (minimum) clearance.

  • Escutcheon plates in place. Tight to ceiling with no gaps.

  • No gaps or missing plates. No broken ceiling tiles around the plates.

  • Doors not propped open.

Biomedical/Electrical Safety

  • All medical patient care equipment is labeled and not out of date.

  • Does the equipment have a current Bio-Med sticker with a current date? If out of date the PCE must be removed by Bio-Med

  • Portable PCE is plugged in to maintain charge.

  • Code cart equipment (i.e. defibrillators) are plugged into red electrical outlets when not in use.

  • Code cart is checked each day the department is open.

  • Ensure supplies are not expired and equipment is working correctly.

  • All appliances in patient care areas have initial safety inspection label.

  • Electrical panels are locked and unobstructed.

  • No extension cords are being used for permanently place equipment.


  • All employees are wearing badges and hospital emergency codes. A review is completed with staff.

Infection Control

  • No eating or drinking in patient care areas.

  • Eating and drinking is only allowed in cafeterias, break rooms, private offices.

  • Storage areas are clean and uncluttered.

  • No storage on the floor. No supplies overstocked.

  • No outdated supplies.

  • Check if the department has a system for rotating supplies.

  • No storage close around the tops of the sinks. Under sink cabinets contain only cleaning supplies.

  • Only cleaning supplies can be stored under sinks. No storage allowed within the slash range of the sink.

  • No storage on the floor. (N/A for offices)

  • All corrugated shipping cartons are removed from the clean utility/supply room.

  • Supplies should be removed from original shipping corrugated container.

  • No storage near windows or windowsills. (N/A for offices)

  • Hand hygiene product available.

  • Hand hygiene dispensers in working condition.

  • PPE available as needed.

  • Ensure face shields are readily available.

  • Isolation rooms appropriate.

  • Appropriate signage in place. If airborne precautions, door is closed with negative pressure on and working.

  • Disinfection/sterilization handled properly.

  • Medication not left out unsupervised.

  • Water and/or saline labeled with expiration date.

  • No evidence of holes in walls or ceilings.

  • Ceiling tiles are intact without evidence of mold, staining, cracks, etc.

  • HVAC vents are clean.

  • Comments.

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.