Hospital and Clinic drills

• Hospital building, floor, unit:

• Person interviewed:

• Conducted on

  Date

• Conducted by Mike Sprouse<br>Fire Protection Specialist<br>Michael.Sprouse@vcuhealth.org<br>804.628.6595<br>804.467.5845

  Off

  On

Unit Drilled

• 1) Means of egress were properly maintained on the unit? (No unattended storage, storage not blocking safety equipment)?

  Yes

  No

  N/A

• 2) Could staff locate their "Unit Specific Emergency Preparedness Plan"?

  Yes

  No

  N/A

• 3) Could staff identify the information the Unit Specific Plan contains such as number of patients, relocation/evacuation areas and transportation needs?

  Yes

  No

  N/A

• 4) Could staff identify the primary and secondary exit routes - the closest and most appropriate exits?

  Yes

  No

  N/A

• 5) Could staff locate a fire extinguisher?

  Yes

  No

  N/A

• 6) Did staff know how to use the fire extinguisher?

  Yes

  No

  N/A

• 7) Did staff know the location of Oxygen/Medical gas shutoff valves and which rooms the valves control

  Yes

  No

  N/A

• 8) Did staff know who is authorized to cut off the medical gas shut-off valves?

  Yes

  No

  N/A

• 9) Did staff know if there are adequate portable oxygen tanks available in the event of an oxygen failure?

  Yes

  No

  N/A

• 10) Did staff know to call *500 for fire emergencies? (911 for off-sites)

  Yes

  No

  N/A

• 11) Did staff readily know location of pull station to activate the alarm after dialing *500? (911 for off-sites)

  Yes

  No

  N/A

• 12) Did staff ensure safety of all patients and visitors (close doors, cleared corridors, assisted with evacuation or in defend-in-place buildings - ensure they were in rooms and off unit)?

  Yes

  No

  N/A

• *Note type of staff observed

  Select Licensed Independent Providers Direct Care Providers Support staff

  • Licensed Independent Providers
  • Direct Care Providers
  • Support staff

Score and recommendations

• Very Good - 100 Good 90-99 Fair 75- 89 Poor - 74 or below (requires a re-drill to be performed within 30 days) Please review the following recommendations with your staff.

• Your area did not perform well and a re-drill is required with in next 30 days. Please take time to review procedures with your staff and contact me with any questions.

Observed areas (units on floor not drilled, two floors above the alarm and one below)

• 1) Means of egress were properly maintained on the unit? (No unattended storage, storage not blocking safety equipment)?

  Yes

  No

  N/A

• 2) Was the storage cleared during the alarm?

  Yes

  No

  N/A

• 3) Was "Unit Specific Emergency Preparedness Plan" posted?

  Yes

  No

  N/A

• 4) Did Hospital Personnel close doors during alarm?

  Yes

  No

  N/A

• 5) Did Hospital Personnel assist/notify patients and visitors?

  Yes

  No

  N/A

Fire alarm system

• Did the fire alarm devices work properly (fire doors, horns & strobes)?

  Yes

  No

  N/A

• Time required to complete fire drill:

• Other notes/Work order: