HSC Hazard Surveillance Detection and Safety Survey

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Staff Knowledge

• Staff able to demonstrate knowledge and skill of their role and expected participation in the safety management program?

  Yes

  No

  N/A

• Staff able to demonstrate knowledge and skill of their role and expected participation in the security management program?

  Yes

  No

  N/A

• Staff able to demonstrate knowledge and skill of their role and expected participation in the hazardous materials and waste management program?

  Yes

  No

  N/A

• Staff able to demonstrate how to pull an MSDS for chemicals used?

  Yes

  No

  N/A

• Staff able to demonstrate knowledge and skill of their role and expected participation in the emergency preparedness program?

  Yes

  No

  N/A

• Staff able to demonstrate knowledge and skill of their role and expected participation in the life safety program?

  Yes

  No

  N/A

• Staff able to demonstrate knowledge and skill of their role and expected participation in the utilities management program?

  Yes

  No

  N/A

• Staff able to demonstrate knowledge and skill of their role and expected participation in the medical equipment management program?

  Yes

  No

  N/A

• How are equipment malfunctions reported?

  Yes

  No

  N/A

• Staff able to demonstrate how to pull policies and procedures?

  Yes

  No

  N/A

• How are you trained to operate equipment? What do you do if you are unsure of proper function?

  Yes

  No

  N/A

• Emergency procedures readily available and staff knowledgeable of location and contents?

  Yes

  No

  N/A

• Staff able to locate nearest fire extinguisher, fire pull, gas shut-off?

  Yes

  No

  N/A

• Staff able to demonstrate proper function of Fire Enunciator Panel?

  Yes

  No

  N/A

Observation

• All employees have employment badges on and visible?

  Yes

  No

  N/A

• All non-employes individuals have appropriate badge on and visible?

  Yes

  No

  N/A

• All confidential/PHI is secured without being visible?

  Yes

  No

  N/A

• All areas free from odors?

  Yes

  No

  N/A

• Sharps containers locked and secured to wall/cart?

  Yes

  No

  N/A

• Equipment with current Biomed tags?

  Yes

  No

  N/A

• Child-safe outlet protectors in use?

  Yes

  No

  N/A

• Emergency carts (crash cart, Broselow cart, MH cart) all locked with current documentation?

  Yes

  No

  N/A

• Daily/monthly checklists present and up-to-date for all emergency carts?

  Yes

  No

  N/A

• All medication areas have current expiration date checklists complete?

  Yes

  No

  N/A

• All supply areas have current expiration date checklists complete?

  Yes

  No

  N/A

• Temperature and humidity logs complete for OR area?

  Yes

  No

  N/A

• Bi-monthly cleaning checklists complete for all areas?

  Yes

  No

  N/A

• Refrigerator temperature logs complete and up-to-date?

  Yes

  No

  N/A

• Medication refrigerator: No food items, medications only, expiration dates checked, proper storage of medications?

  Yes

  No

  N/A

• Patient food refrigerator: No staff items, expiration dates checked, all items labeled with expiration dates, temperature monitored?

  Yes

  No

  N/A

• All blanket and fluid warmers temperature checks maintained? Fluids labeled with expiration date?

  Yes

  No

  N/A

• Tissue Freezer: Temperature checks complete and up-to-date, AATB/FDA documents complete and up-to-date, tissue logs complete and accurate, implant log complete and accurate?

  Yes

  No

  N/A

• Blood Glucose testing logs complete?

  Yes

  No

  N/A

• Blood glucose user manual present?

  Yes

  No

  N/A

• Gas cylinders all labeled and tagged appropriately? Removed when empty?

  Yes

  No

  N/A

• Gas cylinders stored upright and secured?

  Yes

  No

  N/A

• Gas cylinder gauges in proper working condition?

  Yes

  No

  N/A

• Are all furniture in proper condition?

  Yes

  No

  N/A

• Staff appears to work ergonomically safe?

  Yes

  No

  N/A

• Exit doors unobstructed?

  Yes

  No

  N/A

• Fire doors free of decorations?

  Yes

  No

  N/A

• Hallways free of equipment? Corridors clear and uncluttered? 8 feet clearance required; may store temporary items on ONE SIDE of hall for short period.

  Yes

  No

  N/A

• Evacuation maps posted next to fire pulls?

  Yes

  No

  N/A

• Exit signs functioning and visible from all areas?

  Yes

  No

  N/A

• All fire extinguishers inspected monthly?

  Yes

  No

  N/A

• Fire extinguishers not blocked by equipment?

  Yes

  No

  N/A

• All doors are positively latching? No wedges used?

  Yes

  No

  N/A

• No fire wall penetrations present?

  Yes

  No

  N/A

• No items stored closer than 18" from ceilings?

  Yes

  No

  N/A

• Cardboard present in restricted areas?

  Yes

  No

  N/A

• All eyewash stations tested and flushed daily/weekly?

  Yes

  No

  N/A

• Gluteraldehyde logs complete and accurate?

  Yes

  No

  N/A

• All chemical containers properly labeled and stored at eye level or lower in order to avoid eye splashing?<br>Labels must include: full name of product, hazard warnings, name, address, emergency phone # of manufacturer

  Yes

  No

  N/A

• Spill kits (formaldehyde, body fluid, mercury) present and available 24 hours/day?

  Yes

  No

  N/A

• All flammable items stored appropriately in fire cabinet?

  Yes

  No

  N/A

• Storage areas free of clutter? Items not stored on floor? No cardboard present?

  Yes

  No

  N/A

• Cord management complete in all areas - no tripping or tangling hazards?

  Yes

  No

  N/A

• All electrical equipment in good condition (cords, plugs, etc.)?

  Yes

  No

  N/A

• Hot water temperature 120 degrees F or less?

  Yes

  No

  N/A

• Walls free of chips and are kept cleaned?

  Yes

  No

  N/A

• Stairwells accessible and free of obstruction?

  Yes

  No

  N/A

• Corridor handrails intact and not loose?

  Yes

  No

  N/A

• All exit doors open from the inside?

  Yes

  No

  N/A

• Bathroom grab bars intact and not loose?

  Yes

  No

  N/A

• Nurse call system is within reach of patient? In bathrooms, pull cords reach the floor, but do not drag on floor?

  Yes

  No

  N/A

• Proper use of bed rails observed?

  Yes

  No

  N/A

• Patient beds/stretchers in lowest position when unattended?

  Yes

  No

  N/A

Medication Areas

• Medication areas locked with restricted access?

  Yes

  No

  N/A

• Medication preparation area clean and unobstructed?

  Yes

  No

  N/A

• No expired medications present?

  Yes

  No

  N/A

• Stored appropriately - no mixing of different administration routes?

  Yes

  No

  N/A

• Look-Alike Sound-Alike practices observed?

  Yes

  No

  N/A

• All medications labeled appropriately?

  Yes

  No

  N/A

National Patient Safety Goals

• 2 patient identifiers used when administering medications/blood, specimens, and while providing treatment?

  Yes

  No

  N/A

• All specimens are labeled in the presence of the patient?

  Yes

  No

  N/A

• All medications are labeled appropriately on and off of the sterile field at all times when removed from the original medication container? Contains medication name, strength, quantity, diluent, expiration date and time if applicable.

  Yes

  No

  N/A

• All medication containers are verified both visually and verbally by 2 individuals when the person preparing is not the person administering?

  Yes

  No

  N/A

• Unlabeled medications are discarded immediately?

  Yes

  No

  N/A

• Medications in all areas are reviewed by entering and exiting staff when changing patient care providers?

  Yes

  No

  N/A

• Physicians mark the surgical/procedural sites?

  Yes

  No

  N/A

• Time-Outs are performed per policy?

  Yes

  No

  N/A

Infection Control

• Stethoscopes cleaned after every use?

  Yes

  No

  N/A

• Proper keyboard and mouse cleaning after every patient?

  Yes

  No

  N/A

• No items stored under sinks (cleaning supplies acceptable - no cloths/paper towels)

  Yes

  No

  N/A

• Exposure Control Plan accessible to staff 24 hours/day and up to date?

  Yes

  No

  N/A

• Scrub sinks clean and working properly?

  Yes

  No

  N/A

• All rooms clean without dust?

  Yes

  No

  N/A

• Patients are educated upon admission on surgical site infection prevention?

  Yes

  No

  N/A

• Ceilings free of stained tiles?

  Yes

  No

  N/A

• All floors appropriately maintained?

  Yes

  No

  N/A

• No boxes/items directly on floor?

  Yes

  No

  N/A

• PPE's available is all areas? Bay drawers, Sub-Steriles, ERCC, Procedure Rooms, Soiled Workrooms?

  Yes

  No

  N/A

• Red biohazard bags available in all areas?

  Yes

  No

  N/A

• Sharps containers not more than 2/3 full?

  Yes

  No

  N/A

• Red hazardous bins are secured and covered properly?

  Yes

  No

  N/A

• Standard precautions observed at all times? View each individual area for repeated behaviors/practices. To include use of PPE's, handwashing, cleaning practices.

  Yes

  No

  N/A

• Blood-Borne pathogens requirements observed? To include no recapping of needles, standard precautions, sharps safety

  Yes

  No

  N/A

• No food present in patient care areas?

  Yes

  No

  N/A

• All employee drink containers covered?

  Yes

  No

  N/A

• All linens stored appropriately (covered)?

  Yes

  No

  N/A

• All autoclaves/sterilization logs complete and accurate?

  Yes

  No

  N/A

• Clean/dirty areas appropriately separated and maintained?

  Yes

  No

  N/A

• Appropriate flow maintained clean to dirty?

  Yes

  No

  N/A

• All air vents free from dust/dirt?

  Yes

  No

  N/A

• Airflow properly maintained?

  Yes

  No

  N/A

• Hand hygiene practices in compliance with requirements?

  Yes

  No

  N/A

• Alcohol hand rubs are well stocked?

  Yes

  No

  N/A

• Sink areas well stocked?

  Yes

  No

  N/A

• No staff with artificial nails?

  Yes

  No

  N/A

• No razors present in facility?

  Yes

  No

  N/A

• Mattresses and pillows all free of tears?

  Yes

  No

  N/A

• Staff able to verbalize contact time for cleaning chemicals?

  Yes

  No

  N/A

• No overflowing trash?

  Yes

  No

  N/A

• Solid surfaces is present on all bottom shelves/carts?

  Yes

  No

  N/A

• All supplies stored appropriately?

  Yes

  No

  N/A

• Patient care items kept in clean areas away from possible contaminants?

  Yes

  No

  N/A

• All control indicators dated when opened (system 1e, blood glucose, etc).

  Yes

  No

  N/A

• Blood glucose machine cleaning documented?

  Yes

  No

  N/A

Safety

• Weather radios turned on, adequate volume and functioning?

  Yes

  No

  N/A

• Walkie-talkies plugged in, visible and easily accessible?

  Yes

  No

  N/A

• Yes

  No

  N/A

Other:

• Yes

  No

  N/A

• Yes

  No

  N/A

• Yes

  No

  N/A

• Yes

  No

  N/A