• Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel


  • Any broken equipment or furniture stored on the unit? • Check for broken/inoperable/no longer in use equipment; look for need repair tags; Check for chipped finishes on patient furniture (arms of chairs; dresser drawers; etc); • Check that protective coverings are intact no rips/tears (linen carts, EKG machines; etc)

  • Are EVS carts attended or locked when unattended? • Check EVS carts to ensure they are attended or locked when unattended

  • Are storage rooms with electrical or mechanical components are locked?<br><br> • Check that all protective boxes, enclosures, cabinets, etc. that house electrical or mechanical components are locked

  • Are refrigerator/freezer temperatures monitored and maintained on the unit/department?<br> • Ask how refrigerators for food/medication are monitored for temperature<br>• Review logs each day for temps-Food Storage (Refrigerator: 40F or below; Freezer: 0F or below)-check logs for daily check documentation<br>• Check for documentation supporting actions taken for out of range temps. (NOTE: 1. The Pyxis refrigerators are monitored by a temperature tracking software in the Pharmacy. 2. Fluid and Blanket warmers are controlled by micro-processors and should not exceed 104F and 130F respectively).

  • Extension cords are NOT used on the unit / department for medical equipment? • Look for power strips used for multiple medical devices

  • Are multi-plug power strip outlets, if seen, used ONLY on non-medical equipment (nurse’s station-computers, monitors, etc)

  • Are there shipping carton boxes in patient care areas? • Shipping carton boxes should not be on patient units

  • Is there evidence of preventative maintenance inspections on medical equipment? <br> • Check for up-to-date inspection stickers-can be 7 different colors to determine frequency<br>• Acceptable date is within one year from last check<br>• Check for cleanliness of medical equipment (dust, fluids)


  • Was patient health information protected by good HIPAA practices? <br> • Computers/WOWs/COWs terminals signed off when not in use.<br>• Pt information is not discussed in public areas<br>• Labels with PHI are discarded in shredding bins<br>• No clipboards displayed as sign-in sheets with multiple patient names on the list<br>• If fax machine is in a public viewing area, patient information is quickly removed<br>• Cannot be overheard or seen by unauthorized persons


  • Are the storage of boxes & patient care items stored properly? • Not directly on the floor<br>• No more than 18 inches from the ceiling<br>• If on bottom shelf; ensure that the last shelf is solid (protection from getting soiled from mopping)

  • Are oxygen or other combustible gas cylinders stored properly?<br> • Secured in a floor stand/carrier, placed in a fire-rated cabinet or secured to the wall by a chain. (not laying on floor or against walls)<br>• Empty and full cylinders stored separately<br>• No combustible material (netting, cardboard) on or around the cylinders?

  • Are fire exits & hallways clear of clutter or obstruction?<br> • Exit corridors must have 8 ft clearance<br>• Equipment in corridors must be actively in use (cleaning carts)<br>• The only exceptions are Code Carts and Isolation Carts

  • Are fire alarm pull stations, fire extinguishers & medical gas zone panels free of obstruction?

  • Are all employee on the unit wearing ID badges appropriately? • ID badges worn above the waist<br>• ID badges display name <br>• ID badge photos are clear


  • Staff attentive to alarms or alert systems in a timely manner? • Call lights<br>• Monitors


  • Is quality improvement data posted in unit? • Compliance with Hand Hygiene; Hospital Acquired Infection rates; Falls; etc


  • Was food & drink stored in designated areas?<br> • No food/ drink at the nursing workstations<br>• No employee food in patient refrigerator <br>• No expired food/ drink in patient refrigerator <br>• No food/drink in laboratory specimen, hazardous storage, window seal

  • OBSERVATION: Was PPE being used correctly? <br> • Staff don PPE appropriately when patient on isolation precautions

  • Was there seperation of clean vs. dirty supplies & equipment?<br> • Look for green tags and coverings for clean items<br>• In small spaces, look for lines separating clean vs. dirty side of room

  • All patient care supplies clean, undamaged, and within expiration date? Look for any expired, damaged or soiled patient care supplies?<br> • Look for expiration dates on labels (syringes, IV fluids, cannulas, tubing, bandages, lab specimen tubes)


  • Are medication rooms clean and uncluttered?

  • Are all medication carts & storage locked for safety or under constant surveillance?<br> • Med carts/rooms are locked<br>• No unsecured medications found on unit <br>• Check pneumatic tube areas, emergency drug boxes, crash carts, patient care areas for insulin pens; unidentified liquids; ointments

  • Code Carts meets the following:<br> • Earliest expiration date on cart is current<br>• Locked & marked with the first drug to expire?<br>• Checked daily and documented on log sheet?<br>• Include defibrillator check?<br>• O2 tank > ¾ full<br>• Cart is clean?


  • Are expiration dates on materials used for point of care testing (blood glucose monitoring) within date and appropriately labeled? <br> Check expiration dates based on date opened: 1) test strip 180 days (6 months); 2) Quality Control (QC) test solution 90 days (3 months); NOTE: Strips & QC solution should be stored between 15-30 C (59-86 F) degrees to match the stringent storage criteria for the glucose monitor

  • Are quality checks and room temperature log completed? Check for Logs: 1) QC check & 2) room temperature


  • Was the team greeted with smiles and introductions?

  • Was a space designated for the team to conduct interviews and file reviews?

  • Did staff promptly answer questions or deliver materials required for review to the tracer team?

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.