IMG Safety Survey 2016

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

• Conducted on

  Date

• Prepared by Chrissy McDaniel

• Personnel present during survey:

Medication

• Are narcotics counted and administered by licensed staff only?

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

• 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)?

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

• High alert medications are labeled in medication area.

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

Emergency Management

• Are evacuation maps accurate and posted in appropriate areas?

  Safe

  At Risk

  N/A

• Is the utilities shut down map posted?

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

Emergency

• The disaster notification list is available.

  Safe

  At Risk

  N/A

Hazard Materials Waste

• Lids are on biohazard bins and doors secured.

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

• Flammable liquids are stored in a proper cabinet.

  Safe

  At Risk

  N/A

• Are hazard materials and waste properly labeled?

  Safe

  At Risk

  N/A

Infection Control

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

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

• Are only approved standardized safety devices stocked?

  Safe

  At Risk

  N/A

• 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.)

  Safe

  At Risk

  N/A

• Are PPE kits available?

  Safe

  At Risk

  N/A

Lab Safety

• Is CLIA/COLA certificate posted and current?

  Safe

  At Risk

  N/A

• Are lab signs posted? Analytical area?

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

• 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)

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

• Are clean supplies not stored with patient specimens?

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

• Has most current package insert for each test performed.

  Safe

  At Risk

  N/A

• All lab policies are signed off by Lab Director.

  Safe

  At Risk

  N/A

• 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.

  Safe

  At Risk

  N/A

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

  Yes

  No

  N/A

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

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

• Quick Test instructions are posted by all kits.

  Safe

  At Risk

  N/A

• 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?

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

Radiology Safety

• Is current certificate for x-Ray posted?

  Safe

  At Risk

  N/A

• Are radiation badges available for personnel involved in radiology?

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

• Does the imprint include tech's initials?

  Safe

  At Risk

  N/A

Safety

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

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

• Are there expired supplies?

  Safe

  At Risk

  N/A

• Are cabinets and drawers containing syringes and needles locked?

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

• Front door has emergency number and nearest hospital posted.

  Safe

  At Risk

  N/A

• Handicap parking is clearly identified.

  Safe

  At Risk

  N/A

• Severe weather protected area marked.

  Safe

  At Risk

  N/A

Rights

• Patient Rights and Responsibilities are posted.

  Safe

  At Risk

  N/A

Security

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

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

Utility Management

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

  Safe

  At Risk

  N/A

Medical Equipment Management

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

  Safe

  At Risk

  N/A

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