Title Page

  • Site conducted

  • Conducted on

  • Prepared by

  • Location

Safety Management

  • Who is responsible for the hospital safety program?

  • What is the title of the person responsible for the safety program?

  • Are there other personnel that has responsibilities for portions of the hospital safety program?

  • List other persons responsible for the safety program.

  • Has the person responsible for the safety program been given authority in writing by the CEO and the board?

  • Has the person responsible for the safety program had training or experience in healthcare safety?

  • Is Security part of Safety Management or a separation function/department?

Safety Committee/Environment of Care (EOC) Committee

  • What is the name and title of the safety committee/Environment of Care (EOC) committee chairman?

  • What is the frequency of meetings of the Safety/EOC committee?

  • Who maintains the committee minutes?

  • Are committee minutes or summaries of the meetings shared with other functions or committees?

  • Who are the minutes shared with?

  • Are follow up actions included and documented in old business items within the minutes?

  • What departments are represented on the committee?

  • Are attendance of members included in the minutes?

  • Are incident trending data included within the minutes that address frequency of incidents and categorized by severity and frequency by departments/units?

  • If trending data is included in the committee minutes, what areas does it include?

  • Are there sub-committees developed on focused safety issues that report to the Safety/EOC committee?

  • If sub-committees are used, what areas do they address? (employee or WC, security, fire safety)

Education-safety and security

  • For NEW EMPLOYEE orientation, is the hospital safety program addressed that includes hazards identification and accident reporting?

  • Is annual education provided for ALL EMPLOYEES that include accident trends, accident reporting and follow up?

  • For specific issues for types of accidents such as needle sticks, proper lifting to reduce muscle strains/sprains, investigation of accident causes provided to ALL STAFF MEMBERS as well as problem areas for high risk departments provided?

  • Is the education position responsible for hospital education programs included on the hospital safety/EOC committee?

Human Resources/Employee Health

  • Does the employee health function report to Human Resources?

  • Is the Human Resources department responsible for workers compensation?

  • Is there a specific policy for workers compensation that addresses safety, accident prevention, accident/illnesses reporting, claims processing?

  • What role, if any, does the Human Resources department play in the hospital safety program?

  • If Human Resources manages the workers compensation program, are REPEAT ACCIDENTS by employees monitored and a summary provided to the Safety Officer?

  • How are department directors held accountable for accidents within their department (annual evaluations)?

  • Is there a job description for EACH EMPLOYEE that includes the physical requirements including lifting, patient transfer, material movement, etc.?

Life Safety and Fire Protection Issues

  • Are fire drills conducted once per shift per quarter in each building?

  • Are fire extinguishers checked monthly and dated?

  • Are critiques conducted on all fire drills to evaluate fire safety equipment, building features and staff responses to the fire drill?

  • Are there any dead-end corridors in the hospital, not exceeding 30 feet and the area at the end marked "Not an Exit"?

  • Is the hospital totally sprinklered or partially?

  • Are there laundry or trash chutes used in the facility?

  • If laundry or trash chutes used, are the collection rooms sprinkled and the chute doors equipped with fusible fire links to close?

Emergency Management

  • Are external disaster drills conducted semi annually?

  • Are internal disaster drills conducted?

Hazardous Material Issues

  • Who is responsible for managing the hazardous communication requirements?

  • Are MSDS available to the staff in all areas?

  • Is training provided on the Hazardous Material program and the use of MSDS to all employees?

Medical Equipment Issues

  • Is there a policy that prohibits the use of outside equipment or personally owned equipment from being use in the facility?

  • Is there a medical equipment inventory of all equipment that categorizes the device as high risk or life-support or non-high risk?

  • Is all medical equipment calibrated and checked for risk of use to the employees and patients performed at least annually or more often according to the manufactures recommendations?

  • Is there a biomedical department responsible for checking medical equipment?

Utilities Issues

  • Does the facility utilize Hyperbaric services?

  • Are all requirements of NFPA 99-2012 Chapter 14 for Hyperbaric Chambers met?

Med/Surg Units

  • Are all corridors free from storage and Equipment?

  • Are med/surg unit storage rooms kept in an orderly fashion to access equipment and reduce falling items?

  • Is patient lifting equipment properly storage and accessible?

  • Are ALL patient bathrooms equipped with a locking device accessible by the staff ?

Dietary Issues

  • Are automatic fire-extinguishing systems within the kitchen inspected every six months (discharge of the fire-extinguishing system is NOT required)?

  • Are floors free from water accumulation with emphasis on dish washing areas?

  • Are all hot water pipes insulated to protect dietary staff

  • Are food storage areas well maintained with proper storage of heavy items at floor level and no storage above 18 inches to the sprinkler heads?

  • All all walk-in freezer or cooler units equipped with emergency door handle latches?

  • Are knives or other cutting items stored properly?

  • Are protective gloves provided and used for dietary employees that cut food items?

  • Are head covers required and worn by all persons within the food preparation areas for proper sanitation?

  • Are floor matts provided for slippery areas within the kitchen?

  • Are proper clothing properly worn by dietary workers that includes proper aprons, non-slip foot wear, head covering, etc.?

  • Are cleaning supplies used for ovens/stoves properly stored and labeled and protective clothing worn when cleaning that includes protective eye wear, gloves, etc.?

Imaging Issues

  • Is there a policy regarding pregnant employees working within the department where radiation may cause harm to the unborn fetus?

  • Are dosimeter badges worn by ALL employees and evaluated regularly for excessive exposure?

  • Is annual education on proper techniques proved to all employees responsible for patient transfer or patient movement to and from tables or other equipment where body mechanics are needed?

Outside Issues

  • Is weather, such as snow and ice, a risk to slippy conditions?

  • Is there a contract for ice and snow removal?

  • Are parking lots for visitors and employees well maintained with no tripping hazards such as uneven pavements, pot holes, etc.?

  • Are sidewalks maintained with level walking surfaces and proper marking?

  • Are there outside stairs provided with required handrails?

  • Are perimeter doors properly marked and locked except for designated entrances?

  • Are walkways between buildings in good order with no tripping hazards?

  • Are emergency call stations available in employee and visitor parking lots?

  • Are CCTV's used for parking lots?

  • Is the Emergency entrance well marked and easily identified?

  • Are oxygen and other piped in gas areas kept locked and secured?

Security Issues

  • Who is responsible for hospital security?

  • What type of security personnel are available in the hospital?

  • Are security issues/incidents reported to the appropriated person (risk management, Human Resources, Quality, and safety) involving employees, patients, visitors and physicians?

  • Are "near miss" incidents, such as verbal abuse, threats, spitting, etc., reported?

  • Is deescalation training provided to ALL employees of the hospital include temporary staff?

  • Is there an outside source or a staff person certified to provide deescalation training?

  • Is there 8 hour crisis prevention and deescalation training provided to the following?

  • Are overnight guest allowed that are identified as such with identification of areas accessible to the visitor?

  • Are all outside doors locked that prohibits entry into the hospital during non-visitor hours except for the emergency unit?

  • Are security rounds conducted throughout the hospital during the evening and night shifts?

  • Does the hospital use off-duty police personnel stationed at the Emergency department during the evening and night shifts?

  • Are security personnel equipped with personal protective devices and properly trained on the use of these devices?

  • What security protective devices are used by the security staff?

  • If firearms are used by security personnel, is annual training and certification obtained by all personnel?

Surgery/Obstetrics

Behavioral Health

  • Is the behavioral health unit secure going-in and going-out of the unit with audio and visual alarms?

  • Are there metal detectors or hand held wands available and used prior to entry into the unit?

  • Is there 8 hours of deescalation training to ALL behavior health staff, including temporary staff and hospital staff that may visit the unit for work purposes (housekeeping, dietary, ancillary, etc.)?

  • Are behavioral health security isolation rooms totally free of material or objects that create potential harm to patient and staff?

  • Are cameras used to monitor day rooms or multi-purpose rooms viewable at the nursing stations?

  • Are monitors available at the nursing station that views patients in security isolation rooms?

  • Is the behavior health unit nursing station secure and protected for patients?

  • Are there duress alarms available at the nursing station to call for assistance from agitated or unruly patients?

  • Are the hospital staff responding to a security code from the behavior health unit trained for deescalation and physical threats?

  • Are all patient rooms in the behavioral health unit equipped for suicide prevention?

  • Is there a hospital code specific to elopement from the behavioral health unit?

Special Care Unit

  • Is security provided that limits visitors within the unit?

  • Is equipment maintained in an orderly fashion to allow treatment and reduce tripping from cords and other equipment?

  • Are waiting areas provided that is separate from the special care units and limits the number of visitors allowed?

Emergency Services

  • Is the outside of the Emergency Department well lighted and signs

  • Is the signage proper for ambulatory and ambulance entrances?

  • Are the entrances into the ED well secured and employees protected from intruders?

  • Are duress alarms available within the emergency department to call for assistance for unruly patients/visitors?

  • Is the emergency department provided with "safe rooms" for treatment of patients that are deemed a potential threat to themselves or the staff and located next to or adjacent to the nurses stations and equipped with cameras?

  • Are decontamination facilities and supplies available to treat patients exposed to chemical, biological, radiological or nuclear agents?

  • Are off-duty police officers or in-house security staff stationed nearby or immediately available for threats to the hospital staff?

  • Is the triage area of the Emergency department well protected from patient threats with barriers or bullet proof glass?

Plant Operations/Maintenance

  • Is the emergency power generator tested monthly?

  • Do all subcontractors performing work both inside and outside the facility provide evidence of insurance with a minimum of $1M/$3M?

  • Does all subcontractors or contractors working inside and outside the facility provide evidence of workers compensation?

  • Is there any asbestos currently in the hospital construction?

  • If asbestos is within the facility, is there a current O&M plan (operations and maintenance) available?

OSHA Record keeping & requirements

  • Who maintains OSHA records?

  • Is the OSHA log 300 current within 7 days of every recordable incident and up-to-date?

  • Is there a incident report or OSHA Form 301 available with the OSHA case # for each 300 log entry?

  • Is the OSHA Form 300A summary dated, signed and posted February through April each year?

  • Is there a system available for employees to communicate identified hazards or safety issues?

  • Is there a safety incentive program to recognize employees or department that excel in reducing workplace injuries/illnesses?

  • Are emergency phone numbers readily available to contact in-house or outside agencies in emergency situations, e.g., poison control, local police, decontamination issues, bomb or terrorist threat, etc.?

Central Sterile Supply

  • Is ETO use for sterilization?

Laboratory

  • Is there a eye wash station or a eye wash device available?

  • Is the eye wash station or flushing device checked for proper function and documented?

  • Is there a safety shower available and periodically tested (annually) with documentation?

  • Are chemical stared properly with required labeling for identity and appropriate warning for corrosive, flammable or caustic materials?

  • Are PPE's (personal protective equipment available and used at all lab work stations?

  • Is eating and drinking prohibited in work areas and a break area separated from the lab working areas?

  • Are Lab coats provided and properly stored to minimize contamination to other parts of the hospital?

  • Are face shields and/or eye protection provided and used at work stations where spills or splashes might occur?

  • Are spill kits readily available in all areas of the lab where chemicals are used or stored?

  • Are fume hoods provided for working with flammable and toxic materials and ventilation tested?

  • Are protective gloves worn at all times at laboratory work stations?

  • Is there a written Chemical Hygiene Plan (CHP) current and available in the lab?

  • Is there a policy prohibiting mouth pipetting of blood or Other Potentially Infectious Material (OPIM)?

  • Is there a current written Exposure Control Plan addressing all employees who come in contact with blood-borne pathogens?

  • Does the hospital laboratory have a policy for waste disposal and prohibits pouring chemicals down the drains?

  • Are Material Data Safety sheets current an readily available to lab employees?

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.