Title Page
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Conducted on
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Audited by
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Area audited
Environment of Care
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No cardboard should be present in the area.
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Computer towers are on risers or 6” off the floor.
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Sharps boxes should not exceed ¾ full and should not contain any non-sharps related items
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Personal lotions and sprays are not present
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No items are found under sinks
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Are sinks clear of calcium, lime and rust build-up?
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Chemicals and medical supplies are within date of expiration
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Staff can answer the following regarding MSDS:
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Medications are not outdated.
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Linen is covered or inside a cabinet
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Patient refrigerators: clean, is clear of ice, thermometer is not expired, and logs/documentation is complete
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Blanket warmer logs are completed daily
Life Safety & Emergency Preparedness
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Patient care items are not placed directly on the floor.
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Oxygen and Carbon Dioxide cylinders are properly stored and labeled. Cabinets in which oxygen and carbon dioxide is stored is clean and dust-free.
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Staff know the locations of fire alarm pull stations, extinguishers and oxygen shut-off valves.
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Staff know their departmental disaster preparedness plans.
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Staff know RACE & PASS
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Electrical panels, fire alarm pull stations, extinguishers and gas shut off valves should be free of obstructions within 36”.
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Fire-rated doors can be opened to 90 degrees and are not propped open
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There is at least 18" clearance from all sprinkler heads.
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Fire extinguishers are inspected monthly.
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Call lights are hanging free.
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Floors, ceilings, walls and other surfaces are intact.
Patient Safety/Infection Control
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Food and drink are in designated areas.
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Biohazard waste is appropriately discarded and not overfilled.
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Staff know wet times of purple, orange, red and grey top cleaners
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Supplies and equipment is clearly marked clean vs. dirty.
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Carts and shelving are clean, dust-free, and the bottom shelf is solid.
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Patient information is kept secure and confidential
Staff Standards
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Staff can identify two process improvement initiatives
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Staff badges are worn per policy and clearly visible.
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Staff know how to call security:<br>- Hospital: x50911<br>- OSMI: Tony: 262-0359 or Cato: 262-0238<br>- Off-sites: Call 911
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Staff know how to verify physician privileges
Applicable Areas
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Are you observing a procedure that requires consents, or moderate sedation, or peri-operative exam?
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Are you in Fluoro?
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Code cart logs are completed and up to date. Key lock matches written number in the log.
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Time-out is documented, dated, and timed.
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Medications are secured by lock if not within line-of-sight of technologist.
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Consents are signed
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STOP signs are in use and staff can speak to this processes.
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If medication prep area is located near a sink, it is clearly defined with a barrier
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Syringes are labeled with the name of the drug, and date/time of expiration (1 hour from draw). *Not necessary if there is no interruption from preparation to administration*
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Sterile supplies within the room are kept in a cabinet that can be closed on all 4 sides.
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Are you in iMRI
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Code cart logs are completed and up to date. Key lock matches written number in the log.
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MRI screening form is documented, dated, and timed.
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Consents are signed
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Coils are properly stored and covered (not with linen or chemicals)
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STOP signs are in use and staff can speak to this processes.
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Medications are secured by lock if not within line-of-sight of technologist.
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If medication prep area is located near a sink, it is clearly defined with a barrier
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Syringes are labeled with the name of the drug, and date/time of expiration (1 hour from draw). *Not necessary if there is no interruption from preparation to administration*
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Sterile supplies within the room are kept in a cabinet that can be closed on all 4 sides.
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Is patient/staff dressed appropriately for iMRI?
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iMRI checklist is complete, dated, timed and signed then filed
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Phantom QC is performed weekly and documentation is complete
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Are you in MRI?
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Code cart logs are completed and up to date. Key lock matches written number in the log.
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MRI screening form is documented, dated, and timed before entering Zone III
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Consents are signed (if applicable)
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Coils are properly stored and covered (not with linen or chemicals)
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STOP signs are in use and staff can speak to this processes.
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Medications are secured by lock if not within line-of-sight of technologist.
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If medication prep area is located near a sink, it is clearly defined with a barrier
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Syringes are labeled with the name of the drug, and date/time of expiration (1 hour from draw). *Not necessary if there is no interruption from preparation to administration*
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Sterile supplies within the room are kept in a cabinet that can be closed on all 4 sides.
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Phantom QC is performed weekly and documentation is complete
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Are you in CT?
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Code cart logs are completed and up to date. Key lock matches written number in the log.
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Time-out is documented, dated, and timed.
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Consents are signed
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STOP signs are in use and staff can speak to this processes.
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Medications are secured by lock if not within line-of-sight of technologist.
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If medication prep area is located near a sink, it is clearly defined with a barrier
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Syringes are labeled with the name of the drug, and date/time of expiration (1 hour from draw). *Not necessary if there is no interruption from preparation to administration*
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Sterile supplies within the room are kept in a cabinet that can be closed on all 4 sides.
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Phantom QC is performed daily and documentation is complete
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Are you in NM?
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Code cart logs are completed and up to date. Key lock matches written number in the log.
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Time-out is documented, dated, and timed.
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Consents are signed
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STOP signs are in use and staff can speak to this processes.
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Medications are secured by lock if not within line-of-sight of technologist.
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If medication prep area is located near a sink, it is clearly defined with a barrier
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Syringes are labeled with the name of the drug, and date/time of expiration (1 hour from draw). *Not necessary if there is no interruption from preparation to administration*
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Sterile supplies within the room are kept in a cabinet that can be closed on all 4 sides.
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QC is performed daily and documentation is complete
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Are you in US?
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Code cart logs are completed and up to date. Key lock matches written number in the log.
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Time-out is documented, dated, and timed.
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Consents are signed
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STOP signs are in use and staff can speak to this processes.
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Medications are secured by lock if not within line-of-sight of technologist.
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If medication prep area is located near a sink, it is clearly defined with a barrier
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Syringes are labeled with the name of the drug, and date/time of expiration (1 hour from draw). *Not necessary if there is no interruption from preparation to administration*
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Sterile supplies within the room are kept in a cabinet that can be closed on all 4 sides.
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Are trophon log book entries complete?
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Trophon probes are stored promperly?
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Staff know trophon backup procedures?
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Staff know basic trophon info?
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Are you in Mammo?
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Contrast reaction boxes are completed and up to date. Key lock matches written number in the log.
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Time-out is documented, dated, and timed.
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Consents are signed
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STOP signs are in use and staff can speak to this processes.
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Medications are secured by lock if not within line-of-sight of technologist.
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Syringes are labeled with the name of the drug, and date/time of expiration (1 hour from draw). *Not necessary if there is no interruption from preparation to administration*
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Are you in Nursing?
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Code cart logs are completed and up to date. Key lock matches written number in the log.
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Did the patient have an invasive procedure?
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Is there documentation of a pre-sedation assessment completed?
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Time-out is documented, dated, and timed.
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Consents are signed
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STOP signs are in use and staff can speak to this processes.
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Sterile supplies within the room are kept in a cabinet that can be closed on all 4 sides.
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Is the patient's pain assessed with change in RN caregiver using the appropriate pain scale?
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Is the patient's pain assessment completed per policy?
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Syringes are labeled with the name of the drug, and date/time of expiration (1 hour from draw). *Not necessary if there is no interruption from preparation to administration*
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Are the patient's/family education needs documented
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Is the care plan individualized per patient's needs?
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Does the care plan include a target date for completion?
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Care plans are discontinued with change in phase of care
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Is the patient on a PCA pump?
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Is PCA documented for amount used per shift?
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Is there documentation of individualized education related to patient discharge?
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Is there documentation on the MAR of the patient's education following 1st time medication administration?
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Are the pateint's learning preferences identified?
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If the patient had moderate sedation, is there documentation of the immediate reassessment (airway) prior to moderate sedation?
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Was an immediate post-op note documented before the patient went to the next level of care?
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If the patient has multiple pain medication order, there is clear delineation for when the nurse should administer medication for moderate and/or severe pain?
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Medications are secured by lock if not within line-of-sight of technologist.
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If medication prep area is located near a sink, it is clearly defined with a barrier
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Sterile supplies within the room are kept in a cabinet that can be closed on all 4 sides.
