Audit

Environment of Care

No cardboard should be present in the area.

Computer towers are on risers or 6” off the floor.

Sharps boxes should not exceed ¾ full and should not contain any non-sharps related items

Personal lotions and sprays are not present

No items are found under sinks

Are sinks clear of calcium, lime and rust build-up?

Chemicals and medical supplies are within date of expiration

Staff can answer the following regarding MSDS:

Medications are not outdated.

Linen is covered or inside a cabinet

Patient refrigerators: clean, is clear of ice, thermometer is not expired, and logs/documentation is complete

Blanket warmer logs are completed daily

Life Safety & Emergency Preparedness

Patient care items are not placed directly on the floor.

Oxygen and Carbon Dioxide cylinders are properly stored and labeled. Cabinets in which oxygen and carbon dioxide is stored is clean and dust-free.

Staff know the locations of fire alarm pull stations, extinguishers and oxygen shut-off valves.

Staff know their departmental disaster preparedness plans.

Staff know RACE & PASS

Electrical panels, fire alarm pull stations, extinguishers and gas shut off valves should be free of obstructions within 36”.

Fire-rated doors can be opened to 90 degrees and are not propped open

There is at least 18" clearance from all sprinkler heads.

Fire extinguishers are inspected monthly.

Call lights are hanging free.

Floors, ceilings, walls and other surfaces are intact.

Patient Safety/Infection Control

Food and drink are in designated areas.

Biohazard waste is appropriately discarded and not overfilled.

Staff know wet times of purple, orange, red and grey top cleaners

Supplies and equipment is clearly marked clean vs. dirty.

Carts and shelving are clean, dust-free, and the bottom shelf is solid.

Patient information is kept secure and confidential

Staff Standards

Staff can identify two process improvement initiatives

Staff badges are worn per policy and clearly visible.

Staff know how to call security:
- Hospital: x50911
- OSMI: Tony: 262-0359 or Cato: 262-0238
- Off-sites: Call 911

Staff know how to verify physician privileges

Applicable Areas

Are you observing a procedure that requires consents, or moderate sedation, or peri-operative exam?

Are you in Fluoro?

Code cart logs are completed and up to date. Key lock matches written number in the log.

Time-out is documented, dated, and timed.

Medications are secured by lock if not within line-of-sight of technologist.

Consents are signed

STOP signs are in use and staff can speak to this processes.

If medication prep area is located near a sink, it is clearly defined with a barrier

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*

Sterile supplies within the room are kept in a cabinet that can be closed on all 4 sides.

Are you in iMRI

Code cart logs are completed and up to date. Key lock matches written number in the log.

MRI screening form is documented, dated, and timed.

Consents are signed

Coils are properly stored and covered (not with linen or chemicals)

STOP signs are in use and staff can speak to this processes.

Medications are secured by lock if not within line-of-sight of technologist.

If medication prep area is located near a sink, it is clearly defined with a barrier

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*

Sterile supplies within the room are kept in a cabinet that can be closed on all 4 sides.

Is patient/staff dressed appropriately for iMRI?

iMRI checklist is complete, dated, timed and signed then filed

Phantom QC is performed weekly and documentation is complete

Are you in MRI?

Code cart logs are completed and up to date. Key lock matches written number in the log.

MRI screening form is documented, dated, and timed before entering Zone III

Consents are signed (if applicable)

Coils are properly stored and covered (not with linen or chemicals)

STOP signs are in use and staff can speak to this processes.

Medications are secured by lock if not within line-of-sight of technologist.

If medication prep area is located near a sink, it is clearly defined with a barrier

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*

Sterile supplies within the room are kept in a cabinet that can be closed on all 4 sides.

Phantom QC is performed weekly and documentation is complete

Are you in CT?

Code cart logs are completed and up to date. Key lock matches written number in the log.

Time-out is documented, dated, and timed.

Consents are signed

STOP signs are in use and staff can speak to this processes.

Medications are secured by lock if not within line-of-sight of technologist.

If medication prep area is located near a sink, it is clearly defined with a barrier

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*

Sterile supplies within the room are kept in a cabinet that can be closed on all 4 sides.

Phantom QC is performed daily and documentation is complete

Are you in NM?

Code cart logs are completed and up to date. Key lock matches written number in the log.

Time-out is documented, dated, and timed.

Consents are signed

STOP signs are in use and staff can speak to this processes.

Medications are secured by lock if not within line-of-sight of technologist.

If medication prep area is located near a sink, it is clearly defined with a barrier

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*

Sterile supplies within the room are kept in a cabinet that can be closed on all 4 sides.

QC is performed daily and documentation is complete

Are you in US?

Code cart logs are completed and up to date. Key lock matches written number in the log.

Time-out is documented, dated, and timed.

Consents are signed

STOP signs are in use and staff can speak to this processes.

Medications are secured by lock if not within line-of-sight of technologist.

If medication prep area is located near a sink, it is clearly defined with a barrier

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*

Sterile supplies within the room are kept in a cabinet that can be closed on all 4 sides.

Are trophon log book entries complete?

Trophon probes are stored promperly?

Staff know trophon backup procedures?

Staff know basic trophon info?

Are you in Mammo?

Contrast reaction boxes are completed and up to date. Key lock matches written number in the log.

Time-out is documented, dated, and timed.

Consents are signed

STOP signs are in use and staff can speak to this processes.

Medications are secured by lock if not within line-of-sight of technologist.

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*

Are you in Nursing?

Code cart logs are completed and up to date. Key lock matches written number in the log.

Did the patient have an invasive procedure?

Is there documentation of a pre-sedation assessment completed?

Time-out is documented, dated, and timed.

Consents are signed

STOP signs are in use and staff can speak to this processes.

Sterile supplies within the room are kept in a cabinet that can be closed on all 4 sides.

Is the patient's pain assessed with change in RN caregiver using the appropriate pain scale?

Is the patient's pain assessment completed per policy?

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*

Are the patient's/family education needs documented

Is the care plan individualized per patient's needs?

Does the care plan include a target date for completion?

Care plans are discontinued with change in phase of care

Is the patient on a PCA pump?

Is PCA documented for amount used per shift?

Is there documentation of individualized education related to patient discharge?

Is there documentation on the MAR of the patient's education following 1st time medication administration?

Are the pateint's learning preferences identified?

If the patient had moderate sedation, is there documentation of the immediate reassessment (airway) prior to moderate sedation?

Was an immediate post-op note documented before the patient went to the next level of care?

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?

Medications are secured by lock if not within line-of-sight of technologist.

If medication prep area is located near a sink, it is clearly defined with a barrier

Sterile supplies within the room are kept in a cabinet that can be closed on all 4 sides.

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.