Hospital Safety Management Audit 1.0

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Location
  Address

• Who is responsible for the hospital safety program?

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

  Safety Director

  Safety Manager

  Safety Officer

  Other

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

  Yes

  No

  N/A

• 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?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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?

  Monthly

  Quarterly

  Bi-monthly

  Other

• Who maintains the committee minutes?

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

  Yes

  No

  N/A

• Who are the minutes shared with?

  Quality

  CEO

  Board

  Others

  NA

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

  Yes

  No

  N/A

• What departments are represented on the committee?

  Select Nursing Plant operations Physical Therapy Administration Human Resources Medical Staff Dietary Environmental Services Security Others

  • Nursing
  • Plant operations
  • Physical Therapy
  • Administration
  • Human Resources
  • Medical Staff
  • Dietary
  • Environmental Services
  • Security
  • Others

• Are attendance of members included in the minutes?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Employee accidents

  Security incidents

  Patient incidents

  Visitor incidents

  NA

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

  Yes

  No

  N/A

• 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?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 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?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

Human Resources/Employee Health

• Does the employee health function report to Human Resources?

  Yes

  No

  N/A

• Is the Human Resources department responsible for workers compensation?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 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?

  Yes

  No

  N/A

• 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.?

  Yes

  No

  N/A

Life Safety and Fire Protection Issues

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

  Yes

  No

  N/A

• Are fire extinguishers checked monthly and dated?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Is the hospital totally sprinklered or partially?

  Totally sprinklered

  Partially sprinkled

  No sprinklered

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

Emergency Management

• Are external disaster drills conducted semi annually?

  Yes

  No

  N/A

• Are internal disaster drills conducted?

  Yes

  No

  N/A

Hazardous Material Issues

• Who is responsible for managing the hazardous communication requirements?

• Are MSDS available to the staff in all areas?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

Medical Equipment Issues

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 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?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

Utilities Issues

• Does the facility utilize Hyperbaric services?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Yes

  No

  N/A

Med/Surg Units

• Are all corridors free from storage and Equipment?

  Select Yes No N/A

  • Yes
  • No
  • N/A

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

  Yes

  No

  N/A

• Is patient lifting equipment properly storage and accessible?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

Dietary Issues

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Are all hot water pipes insulated to protect dietary staff

  Yes

  No

  N/A

• 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?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Are knives or other cutting items stored properly?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

Imaging Issues

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 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?

  Yes

  No

  N/A

Outside Issues

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

  Yes

  No

  N/A

• Is there a contract for ice and snow removal?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Are there outside stairs provided with required handrails?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Are CCTV's used for parking lots?

  Yes

  No

  N/A

• Is the Emergency entrance well marked and easily identified?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

Security Issues

• Who is responsible for hospital security?

  Plant Operations

  Security Department

  Safety Director

  Other

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

  Select In-house security staff Contract Security staff Off-duty police Combination of hospital staff and off-duty policy

  • In-house security staff
  • Contract Security staff
  • Off-duty police
  • Combination of hospital staff and off-duty policy

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Emergency Department

  Behavior Health

  Special Care Units

  Security Staff

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 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?

  Yes

  No

  N/A

Surgery/Obstetrics

• Yes

  No

  N/A

Behavioral Health

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 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.)?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

Special Care Unit

• Is security provided that limits visitors within the unit?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

Emergency Services

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

  Yes

  No

  N/A

• Is the signage proper for ambulatory and ambulance entrances?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 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?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

Plant Operations/Maintenance

• Is the emergency power generator tested monthly?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Is there any asbestos currently in the hospital construction?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

OSHA Record keeping & requirements

• Who maintains OSHA records?

  Human Resources

  Risk Manager

  Safety Director

  Plant Operations

  Other

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 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.?

  Yes

  No

  N/A

Central Sterile Supply

• Yes

  No

  N/A

• Is ETO use for sterilization?

  Yes

  No

  N/A

Laboratory

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Yes

  No

  N/A