Audit

Admitting

Horizontal and vertical surfaces are clean.

Trash cans not over filled.

Hand hygiene products available.

PPE available. Appropriate PPE used by staff.

Sharps containers less than 3/4 full.

Sharps containers are on IV trays.

IV start trays clean.

Medication preparation area clean, organized and ready for use.

ENDO

Horizontal and vertical surfaces are clean.

Trash cans and linen hampers not over filled. Trash and linen handled per policy. Suction canisters are handled per policy.

Hand hygiene products available.

PPE available. Appropriate PPE used by staff

Sharps containers less than 3/4 full.

Sharps containers secured properly.

Scope cleaning is done according to manufacturer's instructions.

Scopes are labeled and stored according to policy.

Bathroom is clean.

No paper supplies or patient care items stored under sinks.

Procedure room, including Anesthesia Carts, are cleaned and disinfected between patients.

Safe medication preparation and administration practices are followed. IV bags are not spiked more than 1 hour prior to use.

DSD's are maintained and operated according to manufacturer's instructions. Logs are maintained.

Procedure rooms are terminally cleaned at the end of the day.

OR

Horizontal and vertical surfaces are clean.

Trash cans and linen hampers are emptied between each case (PE tubes exempt). Trash and linen handled per policy.

Hand hygiene products available.

PPE available. Appropriate PPE used by staff

Sharps containers less than 3/4 full.

Sharps containers secured properly.

No paper supplies or patient care items stored under the sink.

Safe medication preparation and administration practices are followed.

Operating room, including Anesthesia Carts, are cleaned and disinfected between patients.

Containers are securely closed for transport.

All OR's are terminally cleaned at the end of the day.

Sterilizers are tested daily according to manufacturer's instructions.

Sterile processing and storage is done according to policy.

Cidex trays have expiration date and are not expired.

Log books are complete and up to date. Cidex test strips, biological indicators, immediate use, chemical indicators, mechanical indicators

Sterilization equipment is in good working condition

Preventive maintainance program is in place for sterilizers.

Employee protection measures are implemented during sterile processing.

Event related sterilization packaging is used.

Surgical teams are observed during procedure and masks are securely in place prior to entering the OR.

All head and facial hair is covered.

Doors are completely closed.

Time out process completed according to policy.

PACU

Horizontal and vertical surfaces are clean.

Trash cans and linen hampers not over filled. Trash and linen handled per policy.

Hand hygiene products available.

PPE available. Appropriate PPE used by staff

Sharps containers less than 3/4 full.

Sharps containers secured properly.

Glucose monitor clean and only one time use lancets are available.

Bathrooms are clean.

No paper supplies or patient care items stored under the sink.

Crash Cart checked.

Medication preparation area clean, organized and ready for use.

Safe medication preparation and administration practices are followed.

Patient bays and carts are cleaned and disinfected according to procedure between each patient.

DWA

Horizontal and vertical surfaces are clean.

Trash cans not over filled.

Hand hygiene products available.

PPE available. Appropriate PPE used by staff.

Food stored and distributed according to policy. Food area clean.

Preventing SSI included in patient discharge instructions.

No paper supplies or patient care items stored under the sink.

Nurses stations

Horizontal and vertical surfaces are clean and free of clutter.

No food present, only drinks with lids.

Hand hygiene products available.

Linen

Clean linens are in good condition.

Clean linen is stored in a covered cart.

Soiled linen bagged for transport.

Soiled linen hampers have impervious liner or are emptied regularly.

Soiled linen is removed from building on a regular schedule.

Clean and dirty linen are kept separate.

Hazardous/biological waste

Door is labeled. Biohazard symbol on door. Emergency call button operational.

Waste containers have correct emblem, are dated and bags are correctly tied and closed.

Room is clean and uncluttered.

OSHA compliant storage containers are used. Including sharps containers.

Pick up for transfer is on a specified schedule.

Containers are not overfilled.

Appropriate waste manifests are maintained.

Red bags are available in each regulated medical waste container.

Eye wash station is available.

Trash

Door is labeled. Room is clean and uncluttered. Trash is in appropriate bag.

Pick up for transfer is on a specified schedule.

Clean Storage areas - clean utility, equipment, sterile items, supplies, receiving,

Horizontal and vertical surfaces are clean. Area is clean and uncluttered.

Items are clean and ready to use.

Supplies are at least 18 inches from the ceiling and 6 inches from the floor.

No patient care items or paper products are stored under sinks.

Refrigerators

Daily temperature is checked and recorded appropriately on medication refrigerators. Correct temp range 36-46F

Refrigerators have single uses. Medication, Staff Food, Patient Supplies. No batteries should be stored in the refrigerator.

Items are appropriately labeled.

Refrigerators are routinely cleaned and cleaning is documented.

Halls

Uncluttered

Floors and walls are clean.

No stained ceiling tiles.

Unobstructed access to exits.

Offices/reception

Horizontal and vertical surfaces and floors are clean.

Trash / recycle is not overflowing.

Area in uncluttered.

Waiting room

Horizontal, vertical surfaces and floors are clean.

Trash is not overflowing.

Coffee area is clean.

Area is uncluttered.

Bathrooms

All surfaces are clean.

Hand washing supplies are available.

Trash not overflowing.

Hand Hygiene

Sinks for handwashing are appropriately stocked with soap, paper towels and waste can.

Sinks are available in all areas. If not available, Alcohol hand rubs are available.

Alcohol hand rubs are availalbe near patient care areas and other areas as needed.

Placement of alcohol hand rubs comply with regulations.

Hand hygiene is monitored for staff compliance.

HCW do not wear artificial nails. Nail polish is less than 4 days old.

Only hospital approved hand lotion is available, so glove protection is not compromised.

Staff Knowledge

Staff know how to access policies and procedures.

Staff demonstrate proper hand hygiene technique.

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.