Title Page
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Conducted on
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Prepared by
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Location
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Detailed Location
- GPU Common areas
- ***AT Bldg/TX Mall***
- GPU Food Service West Lake / Pod H
- 3N1 APU
- GPU Pod HMH
- HR / IT / Safety Offices / Rehab Offices /
- 1S1 FSU
- GPU Pod B
- Food Service East Lake-both levels
- 1N1 APU
- Security / PERT /Social Work / FSU Psychology Area / Med Staff Office
- GPU Pod D
- 2N1 APU
- FSU/APU/AT Bldg Yard Spaces/Sidewalks
- 2S1 FSU
- Educational Services
- GPU Pod E
- Dental Office 0N3 / Psychology Area
- 2N3 FSU
- GPU Lab
- Medical Records / SB / Accounting-includes patient funds /Admin / CNO /
- Pharmacy
- GPU OT and Rehab Areas
- ETRU
- 3S1 FSU
- 0N3 Offices / Central Supply / Housekeeping / Basement Corridor / QM
- ***1N3***New ward scheduled to open 1 Jul 20
- ***3N3***New ward scheduled to open 1 Jul 20
Infection Control (IC) EOC Checklist
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IC 1. Flooring surfaces are:▪ Intact▪ Undamaged▪ Clean and free of slip and trip hazards▪ Wet floor signs are used appropriately
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What is the likelihood to harm a patient / staff / Visitor?
- High: Could directly lead to harm without need for other significant circumstances or failures.--Likely
- Moderate: Could cause harm directly, but more likely to cause harm as a contributing factor in the presence of special circumstances or additional failures.--Possible
- Low: Undermines safety/quality or contributes to an unsafe environment, but very unlikely to directly contribute to harm.--Rare
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Is the problem…
- Widespread: issue is “pervasive at the organization” --Process failure/systemic failure --Majority of patients are/could be impacted
- Pattern: issue has potential to “impact more than a limited number of patients impacted” -- Process variation -- > or = 3 but less than 50% patients impacted
- Limited: issue is a “unique occurrence” -- Outlier -- Not representative of routine/regular practice
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IC 2. Ceiling surfaces are:▪ Intact▪ Undamaged▪ Clean and free of stains
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What is the likelihood to harm a patient / staff / Visitor?
- High: Could directly lead to harm without need for other significant circumstances or failures.--Likely
- Moderate: Could cause harm directly, but more likely to cause harm as a contributing factor in the presence of special circumstances or additional failures.--Possible
- Low: Undermines safety/quality or contributes to an unsafe environment, but very unlikely to directly contribute to harm.--Rare
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Is the problem…
- Widespread: issue is “pervasive at the organization” --Process failure/systemic failure --Majority of patients are/could be impacted
- Pattern: issue has potential to “impact more than a limited number of patients impacted” -- Process variation -- > or = 3 but less than 50% patients impacted
- Limited: issue is a “unique occurrence” -- Outlier -- Not representative of routine/regular practice
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IC 3. Laminates, countertops, and other solid surfaces are:▪ Intact▪Undamaged▪ Clean and free of stains
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What is the likelihood to harm a patient / staff / Visitor?
- High: Could directly lead to harm without need for other significant circumstances or failures.--Likely
- Moderate: Could cause harm directly, but more likely to cause harm as a contributing factor in the presence of special circumstances or additional failures.--Possible
- Low: Undermines safety/quality or contributes to an unsafe environment, but very unlikely to directly contribute to harm.--Rare
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Is the problem…
- Widespread: issue is “pervasive at the organization” --Process failure/systemic failure --Majority of patients are/could be impacted
- Pattern: issue has potential to “impact more than a limited number of patients impacted” -- Process variation -- > or = 3 but less than 50% patients impacted
- Limited: issue is a “unique occurrence” -- Outlier -- Not representative of routine/regular practice
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IC 4. Furnishings are clean and in good condition; free of rips, tears or other physical damage? (e.g. mattresses, chairs, couches, tables, lamps, etc.)
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What is the likelihood to harm a patient / staff / Visitor?
- High: Could directly lead to harm without need for other significant circumstances or failures.--Likely
- Moderate: Could cause harm directly, but more likely to cause harm as a contributing factor in the presence of special circumstances or additional failures.--Possible
- Low: Undermines safety/quality or contributes to an unsafe environment, but very unlikely to directly contribute to harm.--Rare
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Is the problem…
- Widespread: issue is “pervasive at the organization” --Process failure/systemic failure --Majority of patients are/could be impacted
- Pattern: issue has potential to “impact more than a limited number of patients impacted” -- Process variation -- > or = 3 but less than 50% patients impacted
- Limited: issue is a “unique occurrence” -- Outlier -- Not representative of routine/regular practice
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IC 5. Patient care and medications refrigerators are:▪ Labeled▪Clean▪ Logs are maintained & actions documented for failed readings
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What is the likelihood to harm a patient / staff / Visitor?
- High: Could directly lead to harm without need for other significant circumstances or failures.--Likely
- Moderate: Could cause harm directly, but more likely to cause harm as a contributing factor in the presence of special circumstances or additional failures.--Possible
- Low: Undermines safety/quality or contributes to an unsafe environment, but very unlikely to directly contribute to harm.--Rare
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Is the problem…
- Widespread: issue is “pervasive at the organization” --Process failure/systemic failure --Majority of patients are/could be impacted
- Pattern: issue has potential to “impact more than a limited number of patients impacted” -- Process variation -- > or = 3 but less than 50% patients impacted
- Limited: issue is a “unique occurrence” -- Outlier -- Not representative of routine/regular practice
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IC 6. Patient foods are dated, labelled and within expiration ranges?
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What is the likelihood to harm a patient / staff / Visitor?
- High: Could directly lead to harm without need for other significant circumstances or failures.--Likely
- Moderate: Could cause harm directly, but more likely to cause harm as a contributing factor in the presence of special circumstances or additional failures.--Possible
- Low: Undermines safety/quality or contributes to an unsafe environment, but very unlikely to directly contribute to harm.--Rare
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Is the problem…
- Widespread: issue is “pervasive at the organization” --Process failure/systemic failure --Majority of patients are/could be impacted
- Pattern: issue has potential to “impact more than a limited number of patients impacted” -- Process variation -- > or = 3 but less than 50% patients impacted
- Limited: issue is a “unique occurrence” -- Outlier -- Not representative of routine/regular practice
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IC 7. Stored supplies are elevated off the floor with solid surface bottom shelving?
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What is the likelihood to harm a patient / staff / Visitor?
- High: Could directly lead to harm without need for other significant circumstances or failures.--Likely
- Moderate: Could cause harm directly, but more likely to cause harm as a contributing factor in the presence of special circumstances or additional failures.--Possible
- Low: Undermines safety/quality or contributes to an unsafe environment, but very unlikely to directly contribute to harm.--Rare
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Is the problem…
- Widespread: issue is “pervasive at the organization” --Process failure/systemic failure --Majority of patients are/could be impacted
- Pattern: issue has potential to “impact more than a limited number of patients impacted” -- Process variation -- > or = 3 but less than 50% patients impacted
- Limited: issue is a “unique occurrence” -- Outlier -- Not representative of routine/regular practice
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IC 8. Corrugated cardboard is minimized in patient care areas and/or prohibited in sterile storage areas according to policy?
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What is the likelihood to harm a patient / staff / Visitor?
- High: Could directly lead to harm without need for other significant circumstances or failures.--Likely
- Moderate: Could cause harm directly, but more likely to cause harm as a contributing factor in the presence of special circumstances or additional failures.--Possible
- Low: Undermines safety/quality or contributes to an unsafe environment, but very unlikely to directly contribute to harm.--Rare
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Is the problem…
- Widespread: issue is “pervasive at the organization” --Process failure/systemic failure --Majority of patients are/could be impacted
- Pattern: issue has potential to “impact more than a limited number of patients impacted” -- Process variation -- > or = 3 but less than 50% patients impacted
- Limited: issue is a “unique occurrence” -- Outlier -- Not representative of routine/regular practice
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IC 9. Cabinets located under sinks are not used to store clean supplies or equipment?
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What is the likelihood to harm a patient / staff / Visitor?
- High: Could directly lead to harm without need for other significant circumstances or failures.--Likely
- Moderate: Could cause harm directly, but more likely to cause harm as a contributing factor in the presence of special circumstances or additional failures.--Possible
- Low: Undermines safety/quality or contributes to an unsafe environment, but very unlikely to directly contribute to harm.--Rare
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Is the problem…
- Widespread: issue is “pervasive at the organization” --Process failure/systemic failure --Majority of patients are/could be impacted
- Pattern: issue has potential to “impact more than a limited number of patients impacted” -- Process variation -- > or = 3 but less than 50% patients impacted
- Limited: issue is a “unique occurrence” -- Outlier -- Not representative of routine/regular practice
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IC 10. Clean equipment and supplies, including linen, are segregated from dirty and are stored according to policy?
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What is the likelihood to harm a patient / staff / Visitor?
- High: Could directly lead to harm without need for other significant circumstances or failures.--Likely
- Moderate: Could cause harm directly, but more likely to cause harm as a contributing factor in the presence of special circumstances or additional failures.--Possible
- Low: Undermines safety/quality or contributes to an unsafe environment, but very unlikely to directly contribute to harm.--Rare
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Is the problem…
- Widespread: issue is “pervasive at the organization” --Process failure/systemic failure --Majority of patients are/could be impacted
- Pattern: issue has potential to “impact more than a limited number of patients impacted” -- Process variation -- > or = 3 but less than 50% patients impacted
- Limited: issue is a “unique occurrence” -- Outlier -- Not representative of routine/regular practice
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IC 11. Clean linen is stored inside a dedicated room or is covered?
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What is the likelihood to harm a patient / staff / Visitor?
- High: Could directly lead to harm without need for other significant circumstances or failures.--Likely
- Moderate: Could cause harm directly, but more likely to cause harm as a contributing factor in the presence of special circumstances or additional failures.--Possible
- Low: Undermines safety/quality or contributes to an unsafe environment, but very unlikely to directly contribute to harm.--Rare
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Is the problem…
- Widespread: issue is “pervasive at the organization” --Process failure/systemic failure --Majority of patients are/could be impacted
- Pattern: issue has potential to “impact more than a limited number of patients impacted” -- Process variation -- > or = 3 but less than 50% patients impacted
- Limited: issue is a “unique occurrence” -- Outlier -- Not representative of routine/regular practice
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IC 12. Sharps containers are maintained less than 2/3 full?
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What is the likelihood to harm a patient / staff / Visitor?
- High: Could directly lead to harm without need for other significant circumstances or failures.--Likely
- Moderate: Could cause harm directly, but more likely to cause harm as a contributing factor in the presence of special circumstances or additional failures.--Possible
- Low: Undermines safety/quality or contributes to an unsafe environment, but very unlikely to directly contribute to harm.--Rare
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Is the problem…
- Widespread: issue is “pervasive at the organization” --Process failure/systemic failure --Majority of patients are/could be impacted
- Pattern: issue has potential to “impact more than a limited number of patients impacted” -- Process variation -- > or = 3 but less than 50% patients impacted
- Limited: issue is a “unique occurrence” -- Outlier -- Not representative of routine/regular practice
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IC 13. Needles, sharps, and syringes are secured when unattended?
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What is the likelihood to harm a patient / staff / Visitor?
- High: Could directly lead to harm without need for other significant circumstances or failures.--Likely
- Moderate: Could cause harm directly, but more likely to cause harm as a contributing factor in the presence of special circumstances or additional failures.--Possible
- Low: Undermines safety/quality or contributes to an unsafe environment, but very unlikely to directly contribute to harm.--Rare
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Is the problem…
- Widespread: issue is “pervasive at the organization” --Process failure/systemic failure --Majority of patients are/could be impacted
- Pattern: issue has potential to “impact more than a limited number of patients impacted” -- Process variation -- > or = 3 but less than 50% patients impacted
- Limited: issue is a “unique occurrence” -- Outlier -- Not representative of routine/regular practice
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IC 14. Required hand hygiene practices are followed?
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What is the likelihood to harm a patient / staff / Visitor?
- High: Could directly lead to harm without need for other significant circumstances or failures.--Likely
- Moderate: Could cause harm directly, but more likely to cause harm as a contributing factor in the presence of special circumstances or additional failures.--Possible
- Low: Undermines safety/quality or contributes to an unsafe environment, but very unlikely to directly contribute to harm.--Rare
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Is the problem…
- Widespread: issue is “pervasive at the organization” --Process failure/systemic failure --Majority of patients are/could be impacted
- Pattern: issue has potential to “impact more than a limited number of patients impacted” -- Process variation -- > or = 3 but less than 50% patients impacted
- Limited: issue is a “unique occurrence” -- Outlier -- Not representative of routine/regular practice
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IC 15. Medications and supplies are maintained within their respective expiration ranges.
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What is the likelihood to harm a patient / staff / Visitor?
- High: Could directly lead to harm without need for other significant circumstances or failures.--Likely
- Moderate: Could cause harm directly, but more likely to cause harm as a contributing factor in the presence of special circumstances or additional failures.--Possible
- Low: Undermines safety/quality or contributes to an unsafe environment, but very unlikely to directly contribute to harm.--Rare
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Is the problem…
- Widespread: issue is “pervasive at the organization” --Process failure/systemic failure --Majority of patients are/could be impacted
- Pattern: issue has potential to “impact more than a limited number of patients impacted” -- Process variation -- > or = 3 but less than 50% patients impacted
- Limited: issue is a “unique occurrence” -- Outlier -- Not representative of routine/regular practice
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IC 16. Ice machines and coffee spouts are free of scale build-up?
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What is the likelihood to harm a patient / staff / Visitor?
- High: Could directly lead to harm without need for other significant circumstances or failures.--Likely
- Moderate: Could cause harm directly, but more likely to cause harm as a contributing factor in the presence of special circumstances or additional failures.--Possible
- Low: Undermines safety/quality or contributes to an unsafe environment, but very unlikely to directly contribute to harm.--Rare
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Is the problem…
- Widespread: issue is “pervasive at the organization” --Process failure/systemic failure --Majority of patients are/could be impacted
- Pattern: issue has potential to “impact more than a limited number of patients impacted” -- Process variation -- > or = 3 but less than 50% patients impacted
- Limited: issue is a “unique occurrence” -- Outlier -- Not representative of routine/regular practice
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IC 17. Patient nutrition stations are clean (ie. Microwave, refrigerator, freezer, countertops, etc)?
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What is the likelihood to harm a patient / staff / Visitor?
- High: Could directly lead to harm without need for other significant circumstances or failures.--Likely
- Moderate: Could cause harm directly, but more likely to cause harm as a contributing factor in the presence of special circumstances or additional failures.--Possible
- Low: Undermines safety/quality or contributes to an unsafe environment, but very unlikely to directly contribute to harm.--Rare
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Is the problem…
- Widespread: issue is “pervasive at the organization” --Process failure/systemic failure --Majority of patients are/could be impacted
- Pattern: issue has potential to “impact more than a limited number of patients impacted” -- Process variation -- > or = 3 but less than 50% patients impacted
- Limited: issue is a “unique occurrence” -- Outlier -- Not representative of routine/regular practice
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IC 18. Do you have any additional comments? If so, please add them here.
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