• Document No.

  • Building, Floor, Department

  • Conducted on

  • Prepared by

  • Add signature

  • Location
  • Director: Manager:

  • Please Note: This Information Is Reported To The Director And Manager For Corrective Action For Clinical Issues Only. All Facility Related Issues Will Be Entered Into Archibus via Safety Operations.

Fire Prevention

  • 001. Are waiting areas open to corridors equipped with smoke detection?

  • 002. Are exit signs readily visible and illuminated?

  • 003. Smoke barrier doors have proper gaps (1/8" max opening between doors and 1/4" from door to floor)?

  • 004. Are smoke barrier doors self closing/automatic?

  • 005. Are windows in smoke doors or walls made of fixed wire glass?

  • 006. Is there a clear space of 18 in. Below sprinkler heads?

  • 007. There are no voids in fire or smoke barriers?

  • 008. Are fire doors free of damage and do they close properly? There are no doors propped or wedged open.

  • 009. Are stairways free of storage?

  • 010. Are pull stations visible?

  • 011. Are fire extinguishers properly charged?

  • 012. Does fire extinguisher inspection tag indicate extinguishers are being inspected monthly?

  • 013. Are fire extinguishers accessible?

  • 014. Are emergency evacuation route signs current?

  • 015. Are wall mounted computers maintained in the closed position when not in use.

  • 016. Are corridor unconstructed by equipment or furniture?

  • 017. Are No Smoking rules followed?

  • 018. Are stairwell doors unlocked going into the stairs from the unit?

  • 019. Can windows in patient rooms be opened in the event event of a fire (using a key or an unlocking tool)? Does staff know location of the tool?

  • 020. Are there at least two posted emergency exits on each unit or floor?

  • 021. Do patient sleep rooms open directly onto a corridor with an exit?

  • 022. Are patient room doors are positive latching?

  • 024. Are all decoration flame retardant?

Medical Equipment

  • 101. Is new, demo, or patient owned equipment checked by Biomed before being placed in service?

  • 102. Staff know the proper procedure for impounding the device following a patient incident?

  • 103. Are crash carts and defibrillators checked daily (checked by unplugging from power source)?

  • 104. Are defibrillators pads current and do not have expired dates?

  • 105. Are wheelchairs, IV poles, walkers, and crutches clean and in good condition?

  • 106. Does all medical equipment and inspection tags/stickers as to when the next inspection is due?

  • 107. Are inspections on medical equipment being completed in a timely manner?

  • 108. Are equipment operators manuals readily available?

Utilities Management

  • 201. Are fluorescents lights equipped with working bulbs?

  • 202. Do emergency lights work properly in areas provided?

  • 203. Are wall outlets child proof in areas needed?

  • 204. All electrical panels in closets are secured and are not hampered by items being stored in closets?

  • 205. Is electrical equipment and wiring undamaged?

  • 206. There are no portal space heaters in the area?

  • 207. Extension cords are not used (Exception: Emergency and/or single not ganged fused circuit breaker bars)?

  • 208. Wall outlets are not overloaded?

  • 209. Are isle ways obstructed by computer/phone cables?

  • 210. Are medical Gas Valves accessible, labeled, and clean?

  • 217. Are all heat producing devices (toaster, coffee pots, etc.) unplugged when not in use?

Hazardous Materials

  • 301. Is the hazardous chemical inventory current?

  • 302. Staff know how to retrieve SDS (MSDS)?

  • 303. Are all chemicals properly labeled?

  • 304. Are stored chemicals properly secured?

  • 305. Is the soiled utility room secured and/or toxic material secured?

  • 306. Are cleaning products/chemicals stored properly and away from clinical supplies?

  • 307. Are waist/used chemicals disposed of properly?

  • 308. Are chemicals stored in the proper storage cabinets according to their compatibility?

  • 309. Are emergency eyewash stations and safety showers available in required areas?

  • 310. Are plumbed emergency eyewash station tested weekly?

Safety Management

  • 401. Are medication and specimen refrigerators free of food?

  • 402. Are refrigerators clean?

  • 403. Are refrigerator temperature logs current?

  • 404. Are specimens and medications stored in a separate refrigerators? (In patient care areas, a separate refrigerator is used for the following: unit medications, patient food, staff food, and patient specimens.)

  • 405. Is food consumption, including drinking, prohibited in patient care areas?

  • 406. Is infectious waist disposed of properly?

  • 407. Are medications and/ supplies current and do not have expiration dates?

  • 408. Are sterile and clean supplies stored separately?

  • 409. Are all sterile/high level disinfected items are stored at least 10" off the floor, 6" from outside walls, and 18" from ceiling fixtures?

  • 410. Are linen cart flaps maintained in the closed position when not in use?

  • 411. Are Sharps containers less than 3/4 full?

  • 412. Are gas cylinders properly stored?

  • 414. There are no damaged floor tiles, torn carpet, or trip hazards?

  • 415. There are no damaged/missing ceiling tiles?

  • 416. Glutaraldehyde/Cidex is not used in this area?

  • 417. Cidex OPA Test strips are present if OPA is used and the test strip bottle is dated with discard date?

Emergency Management

  • 501. Is there an Emergency Procedure Manual (EPM) posted?

  • 502. Is the Emergency Procedure Manual up to date?

  • 503. Th fire alarm location page and other emergency announcements are clearly audible in this area?

  • 504. Does the department have a current staff recall list?


  • 601. Are valuables secured (purses, expensive equipment, etc.)?

  • 602. Are code cart medications secure?

  • 603. Are medication secure - (Note - none should be left in open accessible to patients or on anesthesia carts)?

  • 604. Are fax machines in non-public areas to protect confidential information?

  • 605. Are copy machines in non-public areas to protect confidential information?

  • 606. Patient information is not visible from public spaces?

  • 608. Staff is trained to question unknown individuals and report suspicious behavior?

  • 609. Hazardous material is secured?

  • 610. Name tags available or being worn?


  • 999. Any additional items not noted on the inspection form?

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.