ERNA Environmental Safety Inspection

• Site conducted

• Conducted on

  Date

• Prepared by

• Location
  Address

Patient Confidentiality

• No patient personal information in public; Station and Computer

  Met

  Not Met

  N/A

• Patient is covered during transportation

  Met

  Not Met

  N/A

Infection Control

• Regular and infectious waste disposed in appropriate containers. Not overfilled

  Met

  Not Met

  N/A

• Sharp containers should be tightly closed/sealed at 3/4 full

  Met

  Not Met

  N/A

• Sharps containers present in appropriate locations

  Met

  Not Met

  N/A

• Hand rub dispenser in every clinical room, patient waiting areas, near the elevators and at each sink available

  Met

  Not Met

  N/A

• Is there adequate PPE available?

  Met

  Not Met

  N/A

• Are people trained in the use of PPE?

  Met

  Not Met

  N/A

• Items for CSSD are clean and stacked

  Met

  Not Met

  N/A

• Treatment trolleys are clean and organized

  Met

  Not Met

  N/A

• All the used linens and hamper bags are stored in soiled utility room

  Met

  Not Met

  N/A

• Food is stored and eaten in designated places

  Met

  Not Met

  N/A

• Spill kit available and updated

  Met

  Not Met

  N/A

Facilities

• Patient bathrooms have non-slippery surface. Door can be accessed if locked

  Met

  Not Met

  N/A

• Is adequate lighting in toilet?

  Met

  Not Met

  N/A

• Is the floor/area free from water?

  Met

  Not Met

  N/A

• Are doors locks are working?

  Met

  Not Met

  N/A

• Female and male toilet signs are clear?

  Met

  Not Met

  N/A

• Waiting areas are separately identified with male and female and organized

  Met

  Not Met

  N/A

Store Room

• Each nursing area is to make a list of required stock items by description and code, required levels of stock to be held and minimum levels for re-ordering

  Met

  Not Met

  N/A

• Monitor supply levels and order/re-order as indicated by need or stock level

  Met

  Not Met

  N/A

• The separation of sterile and non-sterile items

  Met

  Not Met

  N/A

• Eliminating unnecessary boxes and wrappings

  Met

  Not Met

  N/A

• Keeping top items 50 cm from ceiling

  Met

  Not Met

  N/A

• Ensuring that there is a heat/smoke detector and sprinkler

  Met

  Not Met

  N/A

• Ensuring staff are aware of the location of the nearest fire extinguisher

  Met

  Not Met

  N/A

• Separate items kept in separate labelled containers or shelf space

  Met

  Not Met

  N/A

• Heavy items at waist height

  Met

  Not Met

  N/A

• Fluids on lower shelves

  Met

  Not Met

  N/A

• No boxes/items stored on the floor

  Met

  Not Met

  N/A

• Use of easy clean, dust free containers

  Met

  Not Met

  N/A

• Ensuring shelves and racks are sturdy and in good condition

  Met

  Not Met

  N/A

• Stacking items on a flat base

  Met

  Not Met

  N/A

• Rotating supplies so that the most recently received supplies are stored behind new stock and thereby ensure use of in-date items from front first

  Met

  Not Met

  N/A

• Not hoarding, hiding and keeping a surplus of supplies

  Met

  Not Met

  N/A

• Stock list displayed at all items for that storeroom

  Met

  Not Met

  N/A

• List identified with Non-stock item

  Met

  Not Met

  N/A

• Each item has shelf or container, label with minimum and maximum level weekly

  Met

  Not Met

  N/A

• No items that are expired or have an expiry date less than 3 months

  Met

  Not Met

  N/A

• No condemned/non-operational items in store

  Met

  Not Met

  N/A

• Store Room temperature and humidity

  Met

  Not Met

  N/A

MSDS Checklist

• MSDS folder available in the area

  Met

  Not Met

  N/A

• MSDS folder arranged based on table of contents

  Met

  Not Met

  N/A

• MSDS list updated annually (inventory list) and MSDS sheets are updated in the folder

  Met

  Not Met

  N/A

• MSDS stocks should be maintained and updated with Minimum and maximum level on weekly basis

  Met

  Not Met

  N/A

• List of staff who have competency checkoff

  Met

  Not Met

  N/A

• CPP: Emergency Hazardous Material Spill Management updated in the folder

  Met

  Not Met

  N/A

• PPE must be available in the MSDS area

  Met

  Not Met

  N/A

• HAZMAT area must be separated from other areas of the facility

  Met

  Not Met

  N/A

• Proper labeling according to hazard rating classification.(Diamond sticker)

  Met

  Not Met

  N/A

• Safety (officer) contact number visible for any suspected or witnessed release of a hazardous material to the environment

  Met

  Not Met

  N/A

Linen (DPP: 30501 /125/30 Ns Patient Linen Management – Nurses Role)

• A minimum/maximum level for linen requirement per unit is established and should be adhered to

  Met

  Not Met

  N/A

• Fresh/clean linen is to be stored separate from dirty/used linen

  Met

  Not Met

  N/A

• Clean linen store is to be secured and preferably locked

  Met

  Not Met

  N/A

• Problems with amounts, availability or quality are to be documented on a Linen Problem log and followed-up

  Met

  Not Met

  N/A

• Daily linen monitoring sheet updated and completed

  Met

  Not Met

  N/A

Medication (DPP: 30501-106-30 NS Medication Management – Ordering and Storage)

• Narcotic cupboard double locked

  Met

  Not Met

  N/A

• Expiry date of stock (included in medication fridge) noted every week

  Met

  Not Met

  N/A

• Medication room temperature and humidity are monitored and recorded

  Met

  Not Met

  N/A

• Medication refrigerator temperature maintained 2 to 8 degree °C and recorded

  Met

  Not Met

  N/A

• No food etc in medication fridge

  Met

  Not Met

  N/A

• Medication storage areas (room and cart) locked (except when in use)

  Met

  Not Met

  N/A

• Cassettes are properly labelled with the name of medication and expiry date

  Met

  Not Met

  N/A

• Medication preparation area is clean, good lighting and closed

  Met

  Not Met

  N/A

• Updated stock medication list

  Met

  Not Met

  N/A

• Drug Formulary

  Met

  Not Met

  N/A

• Approved Abbreviations list /Floor Stock medication policy available

  Met

  Not Met

  N/A

• Externally and internally used products separated

  Met

  Not Met

  N/A

• Any product used on patient (external/internal) to be labelled with date when opened

  Met

  Not Met

  N/A

• Proper removal of medication waste

  Met

  Not Met

  N/A

• LASA and HAM poster updated.

  Met

  Not Met

  N/A

Refrigerators (DPP:0501-034-1432 NS Food and Medication Storage In Unit/Ward Refrigerators)

• Food refrigerator temperatures per shift maintained 0-5 °C and recorded

  Met

  Not Met

  N/A

In the event when the refrigerator temp goes beyond or below prescribed temp:

• An action was taken to correct the malfunction (notify Maintenance Dept.)

  Met

  Not Met

  N/A

• Foods transferred to another refrigerator

  Met

  Not Met

  N/A

• Food is stored and eaten in designated places

  Met

  Not Met

  N/A

• All food placed in refrigerators must be labelled with the patient/staff name and dated 24 hours

  Met

  Not Met

  N/A

• Any food not stored as per this DPP will be removed from the refrigerator and discarded

  Met

  Not Met

  N/A

Housekeeping

• Lockers and cabinets clean

  Met

  Not Met

  N/A

• Walls, floors, furniture, pantry clean

  Met

  Not Met

  N/A

• Cleaning chemicals in product containers with label

  Met

  Not Met

  N/A

• Nothing under the sink

  Met

  Not Met

  N/A

• No unapproved cleaning solutions (e.g., not mentioned in the List of Hazmat)

  Met

  Not Met

  N/A

• Janitor room is locked

  Met

  Not Met

  N/A

• No housekeeping carts left unattended and keep it in proper place

  Met

  Not Met

  N/A

Medical Equipment

• Clinical Equipment (Biomed): Clean

  Met

  Not Met

  N/A

• All equipment has label

  Met

  Not Met

  N/A

• Last service date (PPM)

  Met

  Not Met

  N/A

• Next service date (PPM)

  Met

  Not Met

  N/A

• Next service date not passed

  Met

  Not Met

  N/A

• Tag if out of order equipment

  Met

  Not Met

  N/A

• Non-operational equipment labelled

  Met

  Not Met

  N/A

• Manufacturer's instructions available

  Met

  Not Met

  N/A

• List of biomedical equipment inventory is accessible

  Met

  Not Met

  N/A

• Battery log sheet available with updated data

  Met

  Not Met

  N/A

• Stretchers with straps or side rails, wheelchairs with straps

  Met

  Not Met

  N/A

• Oxygen tanks are stored in appropriate holders

  Met

  Not Met

  N/A

• Keep oxygen tank out of entrance ways and walkways

  Met

  Not Met

  N/A

• Empty cylinders separate from full

  Met

  Not Met

  N/A

• Daily room check list is updated and maintained

  Met

  Not Met

  N/A

POCT

• Control solutions labelled with date of opening and in date

  Met

  Not Met

  N/A

• POCT Consumables stored in accordance to PCLM recommendations

  Met

  Not Met

  N/A

• QC done and results recorded daily

  Met

  Not Met

  N/A

• POCT (Glucose, urine, pregnancy test, etc) competencies list is updated

  Met

  Not Met

  N/A

Emergency Contacts

• Station/telephones (either poster or label on phone): Emergency: X 22222

  Met

  Not Met

  N/A

• Color code emergencies posted

  Met

  Not Met

  N/A

• Radiation safety officer name and contact details

  Met

  Not Met

  N/A

• KFMC safety officer name and contact details

  Met

  Not Met

  N/A

Office/Computer

• Reference manuals;

  Met

  Not Met

  N/A

• Read and sign folder (Polices updated)

  Met

  Not Met

  N/A

• Infection control Manual

  Met

  Not Met

  N/A

• Disaster plans and manuals

  Met

  Not Met

  N/A

• Safety/Equipment manual

  Met

  Not Met

  N/A

• Lab guidelines

  Met

  Not Met

  N/A

• Quality Board – Location/Contents

  Met

  Not Met

  N/A