• Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

Previous department EOC survey

  • Has all previous non-conformities been corrected?

Infection Control

  • Beverages / food at nurses station or medication carts?

  • Linen carts are covered and nothing on top?

  • Nothing under the sinks?

  • Hand washing protocols followed and observed?

  • Sterile package integrity?

  • Patient care equipment is clean and cleaned between patients, not dusty?

  • Torn or ripped mattress, cart pads, wheelchairs, task chairs?

  • Kitchen is clean / food is dated and no partially eaten food stored?

  • artificial nails not seen?

Plant Operations

  • Ceiling tiles look good (not stained or broken)?

  • Electrical areas and panels are secured and accessible, legends in place?

  • Walls free from needing patching or paint?

  • Lighting is adequate and covers are clean?

  • No broken or missing hardware?

  • Plumbing is intact with no leaks?


  • hopper rooms and chemicals are secured, cleaners are labeled, secured carts?

  • High areas are free from dust, all ceiling HVAC vents clean?

  • Overall cleanliness of department is good?

  • Portable fans if in use are cleaned?

  • Floors areas are clean?

Security and Safety

  • Red folder / binder updated with fire drills?

  • Staff wearing ID badges?

  • Valuables are secured?

  • Have the security doors been comprised (combinations written in view, door propped, staff sharing combination)

  • Add media

Emergency Management

  • Unit specific response plans are known by staff and available?

Pharmacy issues

  • Open medications are dated?

  • Refrigerator temperature logs are current daily / values are in range? Temp issues are resolved?

  • Pyxis machine, medication rooms, med carts, medication Refrigerator are secured?

  • Code cart(s) log updated daily, secured and checksheet in use view?

  • All medications are secured?

  • K solutions stored appropriately ?

  • Add media

Life Safety

  • Oxygen, Med gas shutoff valves FE's, pull stations not blocked?

  • No storage of equipment - plugged in corridor outlets - moves in 20 minutes?

  • No storage in the stairways?

  • Fire extinguishers are charged and inspected within 30 days intervals?

  • Storage below 18 inches of sprinkler heads?

  • Doors latch properly, no combustibles on doors, doors are not propped or blocked?

  • < 20% of wall covered (papers notes etc.)?

  • Auto shut off coffee pots, no toasters, no toaster ovens, other?

  • Lift equipment is stored properly / wheels are in the locked position?

  • Integrity of smoke and fire doors are intact with no paper or decorations?

  • Add media

Supply/core areas

  • Soiled linen in carts and linen bags are not on floor?

  • Appropriate use of clean and dirty storage, no cardboard boxes on floor?

  • Food trays are covered?

  • Broken or retired equipment is properly tagged as do not use, staff aware of procedures to remove any broken equipment?

  • Add media

Hazardous Materials

  • Cleaners, chemicals are properly labeled, not opened and secured

  • Full and empty 02 tanks are separated and secured, limit 12 full cylinders in storage areas?

  • RMW is covered, not mixed and stored appropriately

  • Sharps containers are secured and not overfilled?

  • Eyewash stations are inspected weekly?

  • Add media

Patient Advocate

  • Has the care met your expectations?

  • Did the food meet your expectations?

  • Did the overall patient experience meet your expectations?

Equipment and Supplies

  • Supply carts are dust free?

  • The Supply expiration dates are compliant?

  • Integrity of product packaging is intact?

  • Point of care – QC reagents expiration dates are compliant?

  • Blood draw supply expiration dates are compliant?

  • Add media


  • Absence of HIPAA violations, no open charts?

  • Availability of designated bins to dispose of patient health information?

  • Are gray and blue bins secured?

  • Patient health information is in correct containers and not in dept wastepaper baskets?

Top Three Concerns Based from the Hazards Surveillance Report

  • 1) emergency stickers are on telephones?

  • 2) Hallways are free from clutter?

Final Comments, Issues, Photos

  • Add media

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.