• This is your IMG Safety Survey. Please respond within 15 days with corrections. Thank you: Chrissy McDaniel 405-552-2741

  • Conducted on

  • Prepared by Chrissy McDaniel

  • Personnel present during survey:


  • Are narcotics counted and administered by licensed staff only?

  • Are narcotics kept under double lock system and all medications secured in cabinets/closets with locking doors?

  • Are medication samples as well as stock meds checked monthly for expiration?

  • Is the temperature log for the refrigerator in compliance? Review log. Is the refrigerators maintained at 36-45 degrees F (2-8 degrees C)? Is the freezer maintained at 4 degrees F or below (-15 degrees C)?

  • Multi-dose vials are stored with expiration date reflecting 28 days.

  • High alert medications are labeled in medication area.

  • Is NIZ sign posted in medication areas with protocol properly followed?

  • Staff are utilizing two identifiers during medication administration and/or drawing blood.

  • Check emergency box. Are medications expired? Check all logs.

Emergency Management

  • Are evacuation maps accurate and posted in appropriate areas?

  • Is the utilities shut down map posted?

  • Are emergency doorbells, lights, and exit lights in working order?


  • The disaster notification list is available.

Hazard Materials Waste

  • Lids are on biohazard bins and doors secured.

  • There are chemical, Mercury, and mess spill kits available.

  • Flammable liquids are stored in a proper cabinet.

  • Are hazard materials and waste properly labeled?

Infection Control

  • Are all parts of the clinic clean and well-maintained?

  • Are sharps containers mounted and less than 2/3 full? (Check all exam rooms as well as med prep areas.)

  • Are only approved standardized safety devices stocked?

  • Are clean, dirty, and sterile areas marked in autoclave area and is autoclave log current as well as instruments marked appropriately? (Packet has initials of staff, date sterilized, date of expiration, and marked as to the contents or in a clear pack. Packs are good for 5 years.)

  • Are PPE kits available?

Lab Safety

  • Is CLIA/COLA certificate posted and current?

  • Are lab signs posted? Analytical area?

  • Does in-house testing report contain date, time, name of provider, patient's name, initials of tech performing test, test selection, and results?

  • Are chemical and/or biohazard material disposed of properly? Is urine discarded down toilet? Are chemicals disposed according to the guidelines provided in the SDS? (Urine cannot be poured down the sink unless the sink is designated as a biohazard sink)

  • Is an eye wash available in lab? Is it checked weekly with documentation?

  • Are temperature monitors in place and in range in the refrigerator? Documented?

  • Are clean supplies not stored with patient specimens?

  • Are test logs maintained for all tests performed or sent out?

  • Is there a mechanism to track all lab, pathology, and tissue specimens?

  • Are centrifuge RPM's checked yearly with documentation? (2 RPM speeds- one for urine and one for blood.)

  • Are manufacturer maintenance and instrument manuals maintained in the lab?

  • Are test kits stored according to manufacturer's guidelines? (Temperature and humidity monitors in place and in range? Documented?)

  • Are test kits standardized according to kits approved by the quality committee?

  • Are two levels of controls performed on each day of patient testing for glucometers?

  • Has most current package insert for each test performed.

  • All lab policies are signed off by Lab Director.

  • The waived test logs reflect quality controls were conducted each day of patient testing and quality assurance logs are up to date and reviewed by the Lab Director.

  • Are all areas / rooms (fixtures/surfaces, vents) clean and free of dust accumulation?

  • Is there an action plan initiated for each problematic area with documentation?

  • Are there competency checklists with documented training for each person eligible to perform patient testing in the lab?

  • Quick Test instructions are posted by all kits.

  • If a PPMP site, is accuracy of PPMP test results verified at least twice per year and is the proficiency testing rotated between all staff performing patient testing?

  • Are the fire extinguishers located every 75ft and have they been checked appropriately?

Radiology Safety

  • Is current certificate for x-Ray posted?

  • Are radiation badges available for personnel involved in radiology?

  • Are pregnancy signs posted in English and Spanish in radiology room?

  • Is there a private area for patients to change into gowns in the radiology room?

  • Is the approved color-coded radiation sign in the radiology room?

  • Is the techniques chart posted as well as being near and typed in the radiology room?

  • Is there an electrical panel in room labeled "Radiology Room?"

  • Are the lead aprons and gloves hung and in good condition?

  • Is the x-Ray equipment serviced regularly with documentation?

  • Is the x-Ray equipment inspected annually by physicist? Are problems identified and corrected with documentation?

  • Does the imprint include tech's initials?


  • Are items being stored no close than 18" from the ceiling? (If building is sprinkled?)

  • Are childproof locks or dangerous objects out of the reach of children?

  • Are there expired supplies?

  • Are cabinets and drawers containing syringes and needles locked?

  • Battery powered lights required for egress have functional test performed every 30 days for a minimum of 30 seconds.

  • Oxygen tanks are secured in cylinder caddy or bolted to wall.

  • Front door has emergency number and nearest hospital posted.

  • Handicap parking is clearly identified.

  • Severe weather protected area marked.


  • Patient Rights and Responsibilities are posted.


  • Is the staff wearing name tags? (Check all staff.)

  • Is confidentiality maintained throughout? (Fax machine, computer screen, counter tops)

Utility Management

  • Are power outage labels properly placed on electrical box and medication refrigerator?

Medical Equipment Management

  • Equipment has PM stickers current within the last 12 months and are appropriately calibrated.

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