Title Page

  • Conducted on

  • Prepared by

  • Location

  • Conducted By

Observation

  • Staff performing Hand Hygiene?

  • Are there No expired items?

  • Are proper low-level disinfectants available and stored properly?

  • Are clinical areas free from staff food and drinks in accordance with policy?

  • All reference guides (in clinical settings), paper signs are laminated or in protective covering.

  • The staff accurately state the Saniwipe kill/wet times.

  • Is access to eyewash equipment unobstructed and does documentation include weekly checks, in accordance with policy?

  • Are the bottom shelves of racks used for the storage of sterile and clean supplies designed with an impervious material?

  • Are areas under sinks free of any storage of patient care items and other items, such as paper products, that could be damaged or contaminated if the items are exposed to water leaks

  • Is linen stored in a clean room or covered when stored in the hallway or other locations?

  • Are all needles/sharps containers secured to prevent tipping and spilling and are the contents below the full line?

  • Are all hand sanitizer and soap containers filled and within the expiration dates?

  • Is the right to patient privacy protected at all times? Note: Include observations of visual and auditory privacy. For example, Doors and curtains are closed when applicable.

  • Nothing is in the splash zone of the sinks in utility room, medication room, or handwashing stations.

  • Is clean equipment segregated from used or dirty equipment?

  • Observe available medical equipment. If the equipment requires preventative maintenance or testing, is the date on the sticker current?

  • Observe equipment, such as IV poles, carts, beds, furniture, curtains, etc. Are all items clean and free from damage?

  • Patient care items and other clean items are NOT stored on the floor.

  • Clean and sterile patient care items are NOT stored in cardboard boxes AND outside shipping boxes are not used to store items in a clean storage room, in accordance with policy

  • Observe a sample of packaged items stored in clean storage rooms. Are all items within the manufacturers' expiration dates?

  • Observe All carts, tables in clinical areas. They are free of tape residue.

  • All glucometers and point of care testing equipment are clean and free of damage.

  • All mattresses and stretcher pads are free of tears in the vinyl.

  • Biomedical waste containers readily available and not too full.

  • Are all ceiling tiles free from cracks, gaps, soiling and water damage?

  • Are all walls in good condition without holes, water damage, exposed wires, excessive tape, or other damage?

  • Is the area free of dust?

  • Are staff wearing PPE in the Patient room, and not in the hallway?

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.