Executive Safety Rounds

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Housekeeping

• High Reach Horizontal Surfaces are Clean 07.00.00

  Yes

  No

  N/A

• Show Evidence

  Media

• Surfaces are uncluttered and free of dust 07.00.00

  Yes

  No

  N/A

• Show Evidence

  Media

• Sprinkler Heads and Smoke detectors are free of dust and dirt. 11.04.06

  Yes

  No

  N/A

• Show Evidence

  Media

• Vents are free of dust and dirt. 07.00.00

  Yes

  No

  N/A

• Show Evidence

  Media

• Environmental Service carts not left unattended in Corridors. (Hospital Only)

  Yes

  No

  N/A

• Show Evidence

  Media

• Empty pop cans are not stored with patient care items. 07.03.07

  Yes

  No

  N/A

• Show Evidence

  Media

• Vending Machines are clean. 07.03.03

  Yes

  No

  N/A

• Show Evidence

  Media

• Wheels on carts are clean and free of dust and/or debris 07.00.00

  Yes

  No

  N/A

• Show Evidence

  Media

ENVIRONMENTAL

• Doors are not propped open. 11.04.05

  Yes

  No

  N/A

• Show Evidence

  Media

• Ceiling tiles are not stained, missing, or broken. 07.03.04

  Yes

  No

  N/A

• Show Evidence

  Media

• In sprinkled areas, supplies are stored 18 inches from ceiling. 11.04.06

  Yes

  No

  N/A

• Show Evidence

  Media

• Items are not stored within 30" directly in front of electrical panels. 1910.303/NFPA

  Yes

  No

  N/A

• Show Evidence

  Media

• Elevator Areas, Corridors, and Egress routes are free of equipment and any obstructions. 11.04.08

  Yes

  No

  N/A

• Show Evidence

  Media

• Furniture and Equipment removed if in poor condition (cracked, torn, broken, ect) and Maintenance notified. 07.00.00

  Yes

  No

  N/A

• Show Evidence

  Media

PATIENT CONFIDENTIALITY

• Computers are " Logged-off" when staff is not present.

  Yes

  No

  N/A

• Show Evidence

  Media

• Monitor Screens are oriented to protect patient confidential information.

  Yes

  No

  N/A

• Show Evidence

  Media

• Doors are locked to Medical record Storage areas. 10.00.04

  Yes

  No

  N/A

• Show Evidence

  Media

• Check all areas for HIPPAA violations (check trash cans, patient charts, test results, etc)

  Yes

  No

  N/A

• Show Evidence

  Media

WORK PRACTICES

• Staff, Doctors, Volunteers, and Students wearing ID at all times. 04.00.13

  Yes

  No

  N/A

• Show Evidence

  Media

• Proper Lifting Equipment available if needed. (Hospital Only)

  Yes

  No

  N/A

• Show Evidence

  Media

• Only Hospital approved hand lotion is available and in use.

  Yes

  No

  N/A

• Show Evidence

  Media

LIFE SAFETY

• Exit Signs clearly visible and working properly. NFPA 99

  Yes

  No

  N/A

• Show Evidence

  Media

• Fire doors and Emergency exits are unobstructed. Fire extinguishes and fire alarm pull stations and accessible (Not Blocked). 11.04.05/11.04.06

  Yes

  No

  N/A

• Show Evidence

  Media

• Staff is familiar with the location of fire extinguishers, medical gas shut-off valves (if applicable), fire alarm pull stations (if applicable) and notification procedures if there was an Emergency situation in the department. 11.00.02/11.07.01

  Yes

  No

  N/A

• Show Evidence

  Media

STORAGE ISSUES

• Items are not left unattended in corridors. 11.04.08

  Yes

  No

  N/A

• Show Evidence

  Media

• Items are not being stored on the floor. 11.04.08

  Yes

  No

  N/A

• Show Evidence

  Media

• No items (clean or sterile) stored under sinks. In non-patient areas, no paper items or non-labeled chemicals are stored under sinks. 07.02.04/07.02.07

  Yes

  No

  N/A

• Show Evidence

  Media

• Items are not to be stored within the splash zone of the sink (3'). 07.03.05

  Yes

  No

  N/A

• Show Evidence

  Media

• All linen items are stored properly-clean with clean, and dirty with dirty, and covered. 07.04.01/07.04.03

  Yes

  No

  N/A

• Show Evidence

  Media

HAZARDOUS MATERIALS AND WASTE

• Staff knows how to access MSDS information. 11.05.04

  Yes

  No

  N/A

• Tank of Compressed gases (oxygen) are properly stored, not left on empty wheelchairs, stretchers, or left in corridors. Only 1 bottle is allowed to be stored at the Nurse's Station. 1910.253/NFPA 99

  Yes

  No

  N/A

• Show Evidence

  Media

• All Biohazard containers are handled and labeled appropriately. 49 CFR

  Yes

  No

  N/A

• Show Evidence

  Media

• In areas using hazardous materials, emergency phone numbers are posted in the case of a chemical spill. 1910.120

  Yes

  No

  N/A

• Show Evidence

  Media

• All chemicals properly labeled and stored. 11.05.04

  Yes

  No

  N/A

• Show Evidence

  Media

• If eyewash stations are in the department, they are inspected and operated weekly to verify working order, and are unobstructed. ANSI Z358.1

  Yes

  No

  N/A

• Show Evidence

  Media

• Biohazards are disposed of in the proper containers-sharps, bio-bags, etc. 07.03.07/49 CFR 171/1910.1030

  Yes

  No

  N/A

• Show Evidence

  Media

• If a department uses a high level disinfectant for equipment sterilization (Cidex OPA), daily checks are completed and logged.

  Yes

  No

  N/A

• Show Evidence

  Media

• Food and Beverages are not stored or consumed in areas where chemicals are used or stored. 1910.120

  Yes

  No

  N/A

• Show Evidence

  Media

INFECTION PREVENTION

• Staff food/drink items are not in patient care areas (i.e. nurses stations). Staff do not apply lip products in patient areas. 07.01.10

  Yes

  No

  N/A

• Show Evidence

  Media

• Staff belongings are not stored in patient care areas.

  Yes

  No

  N/A

• Show Evidence

  Media

• Sterile/Clean equipment stored (6" from outside wall, 18" from the ceiling, and 6" from the floor) and rotated appropriately. 07.02.04/07.02.07

  Yes

  No

  N/A

• Show Evidence

  Media

• Sterile/Clean equipment not stored together with "dirty" utility items or in traffic areas. 07.02.04/07.02.07

  Yes

  No

  N/A

• Show Evidence

  Media

• Specimens are transported correctly (gloves are used when transporting to soiled utility room, specimens are in bio-hazard whenexiting the department). 1910.1030

  Yes

  No

  N/A

• Show Evidence

  Media

• Linen is covered during transport. 07.04.01/07.04.03

  Yes

  No

  N/A

• Show Evidence

  Media

• All clean linen carts are covered, or in an enclosed room. All dirty linen hamper lids are closed. 07.04.01/07.04.03

  Yes

  No

  N/A

• Show Evidence

  Media

• Areas under sinks show no evidence of mold/mildew growth.

  Yes

  No

  N/A

• Show Evidence

  Media

• Opened and outdated nourishments are removed from refrigerators. 07.02.07

  Yes

  No

  N/A

• Show Evidence

  Media

• Refrigerators and freezers for specimens are properly labeled with a biohazard label. 07.03.07

  Yes

  No

  N/A

• Show Evidence

  Media

• Refrigerated specimens are not stored in with refrigerated food items, and patient food is not stored with staff food in refrigerators. 07.00.00/07.03.07

  Yes

  No

  N/A

• Show Evidence

  Media

• Refrigerators are periodically cleaned inside and out.

  Yes

  No

  N/A

• Show Evidence

  Media

• Dirty Equipment is cleaned before being sent to CPD.

  Yes

  No

  N/A

• Show Evidence

  Media

• PPE is available and used properly. 07.01.01/OSHA 1910.1030

  Yes

  No

  N/A

• Show Evidence

  Media

• Alcohol based hand hygiene products are available for staff. 07.03.05

  Yes

  No

  N/A

• Show Evidence

  Media

• Soap and hand towels are available at each hand washing sink. 07.03.05

  Yes

  No

  N/A

• Show Evidence

  Media

• Sterile supplies are not expired and are labeled with a lot number. 07.02.07

  Yes

  No

  N/A

• Show Evidence

  Media

• No evidence of pests or entranceways for pests. 07.05.01

  Yes

  No

  N/A

• Show Evidence

  Media

• No evidence of poisons used to exterminate pests. 07.05.02

  Yes

  No

  N/A

• Show Evidence

  Media

• Brushes used for cleaning medical equipment evaluated and cleaned daily.

  Yes

  No

  N/A

• Show Evidence

  Media

• Upon opening an in-house processed sterile tray or set, the chemical indicators are validated. 07.02.04

  Yes

  No

  N/A

• Show Evidence

  Media

MEDICAL EQUIPMENT

• Preventive maintenance stickers are up-to-date. 11.08.06

  Yes

  No

  N/A

• Show Evidence

  Media

• ERT carts are checked daily ( seals are not broken).

  Yes

  No

  N/A

• Show Evidence

  Media

• ERT Carts are plugged into red outlets. 11.08.04

  Yes

  No

  N/A

• Show Evidence

  Media

• Emergency equipment/supplies (ambu bag, Ephinephrine, Benadryl, airways) are monitored monthly for expiration.

  Yes

  No

  N/A

• Show Evidence

  Media

• Blanket warmer temperature set at 130 degree F (if not automatically monitored)

  Yes

  No

  N/A

• Show Evidence

  Media

• IV solutions in volumes of 150 ml or greater are warmed to 104 degree F for no longer than 14 days

  Yes

  No

  N/A

• Show Evidence

  Media

• Pour bottle solutions are warmed to 150 degree F for no longer than 3 days

  Yes

  No

  N/A

• Show Evidence

  Media

• All comfort bath warmers are set to 125 degree F +5 degrees

  Yes

  No

  N/A

• Show Evidence

  Media

• Non-functioning electrical and patient care equipment removed from service and Clinical Engineering notified

  Yes

  No

  N/A

• Show Evidence

  Media

• Your HEPA hoods are present, labeled correctly for your department, and plugged in. The hood itself is free from damage or tears.

  Yes

  No

  N/A

• Show Evidence

  Media

ELECTRICAL

• Extension cords are not in use (power strips are permitted). 1910.303/1910.334/NFPA 99 & 70E

  Yes

  No

  N/A

• Show Evidence

  Media

• Electrical equipment (including outlets) are in good repair and are secure. 1910.305/NFPA 70E

  Yes

  No

  N/A

• Show Evidence

  Media

MEDICATION SAFETY

• Medications are secure. 25.01.03

  Yes

  No

  N/A

• Show Evidence

  Media

• Medications are not outdated. 07.00.00

  Yes

  No

  N/A

• Show Evidence

  Media

• Medications are properly labeled with the name of the medication, manufacturer, concentration, lot number, and expiration date in month/day/year format. 25.01.07

  Yes

  No

  N/A

• Show Evidence

  Media

• Multi-dose vials are labeled with the initials of person who opened the vial, and the expiration date (28 days after opening). 07.00.00

  Yes

  No

  N/A

• Show Evidence

  Media

• Pill crushers are clean.

  Yes

  No

  N/A

• Show Evidence

  Media

RADIATION SAFETY ISSUES

• Staff members are wearing appropriate badges (radiation dosimeter). 19.00.01

  Yes

  No

  N/A

• Show Evidence

  Media

• Appropriate shielding is available for patients, staff and visitors. 19.00.01

  Yes

  No

  N/A

• Show Evidence

  Media

• Rooms housing radiation sources are labeled.

  Yes

  No

  N/A

• Show Evidence

  Media

• Lead aprons and gloves are worn when necessary. 19.00.01

  Yes

  No

  N/A

• Show Evidence

  Media

• Lead apron checks are completed annually. 19.00.01

  Yes

  No

  N/A

• Show Evidence

  Media

PATIENT CARE AND NURSING (HOSPITAL ONLY)

• All audible alarms are set on patient care equipment.

  Yes

  No

  N/A

• Show Evidence

  Media

• Emergency pull cords are 4 inches from the floor and free hanging.

  Yes

  No

  N/A

• Show Evidence

  Media

STAFF INTERVIEWS (Instructions: Interview 3 staff members(from different shifts if possible) with the below questions)

• How can you access an MSDS sheet?

  Yes

  No

  N/A

• Do you know who the Safety Officer is and how to contact him/her?

  Yes

  No

  N/A

• How are employees notified if Metro activates one of our disaster plans?

  Yes

  No

  N/A

• Where are the nearest fire extinguishers and AND fire alarm pull station located?

  Yes

  No

  N/A

• How is the fire code announced overhead?

  Yes

  No

  N/A

• Where is the medical gas shutoff valve located?

  Yes

  No

  N/A

TOTAL SCORE