Keep a Safe Environment Audit Tool

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Location
  Address

• Department/Location/Unit

• No cardboard boxes on floor and no corrugated shipping boxes located in areas where sterile supplies are stored

  Yes

  No

  N/A

• All items are stored 18 inches from ceiling/sprinkler system

  Yes

  No

  N/A

• Nothing is stored on the floor except trash bins and large sharps boxes

  Yes

  No

  N/A

• Temporary equipment in corridor placed on one side

  Yes

  No

  N/A

• Sharps containers less than 3/4 full

  Yes

  No

  N/A

• Nothing stored under sinks

  Yes

  No

  N/A

• Linens are covered at all times including in transport

  Yes

  No

  N/A

• Scopes are stored in closed cabinets or closet that is only used for scopes

  Yes

  No

  N/A

• Cabinets, closets, and rooms are not cluttered

  Yes

  No

  N/A

• Please indicate the location of cabinets, closets, or rooms that are cluttered

• Patient refrigerators store only patient food that is labeled and dated

  Yes

  No

  N/A

• Is this section free of additional findings (consider previous EOC report)?

  Yes

  No

  N/A

• Please describe other findings:

• Department in overall good repair

  Yes

  No

  N/A

• Floors dry and free from slipping hazards

  Yes

  No

  N/A

• Parking area, walks, steps, and ramps are free from potholes and debris

  Yes

  No

  N/A

• Describe and list the parking area’s, walks, steps or ramps that need repair

• Walk off mats / non slip strips utilized

  Yes

  No

  N/A

• Carpet and tile intact

  Yes

  No

  N/A

• Ceiling tiles not stained or missing

  Yes

  No

  N/A

• Lighting is adequate and functioning for job performance

  Yes

  No

  N/A

• Is this section free of additional findings (consider previous EOC report)?

  Yes

  No

  N/A

• Please describe other findings:

• Ice machines clean per manufacturers instructions

  Yes

  No

  N/A

• Applicable PPE available for employee use

  Yes

  No

  N/A

• Temperature and humidity’s logged for OR’s, sterile supply rooms, and temps logged for patient medication and food refrigerators, blanket and fluid warmers, tissues and lab reagents

  Yes

  No

  N/A

• Out of range temps / humidity’s with documented actions taken

  Yes

  No

  N/A

• Eye wash stations are properly working, checked weekly

  Yes

  No

  N/A

• Is this section free of additional findings (consider previous EOC report)?

  Yes

  No

  N/A

• Please describe other findings:

• Supplies, needles, and prescription pads are secured

  Yes

  No

  N/A

• Drug cabinets are locked when not in use

  Yes

  No

  N/A

• Narcotics are double secured

  Yes

  No

  N/A

• Crash cart defibrillator activation is documented daily

  Yes

  No

  N/A

• Crash cart opened and items checked monthly

  Yes

  No

  N/A

• Malignant Hyperthermia cart checked monthly

  Yes

  No

  N/A

• Defibrillator and anesthesia machines are inspected and have semi-annual PM’s

  Yes

  No

  N/A

• Bed Rails operate correctly

  Yes

  No

  N/A

• Medications are not expired

  Yes

  No

  N/A

• Open medications are dated / initialed as required

  Yes

  No

  N/A

• Patients are wearing ID’s

  Yes

  No

  N/A

• Is this section free of additional findings (consider previous EOC report)?

  Yes

  No

  N/A

• Please describe other findings:

• Adults: Rooms in which there is a patient at risk for falls clearly marked

  Yes

  No

  N/A

• Pediatrics: Outlet covers installed / available in rooms designated for pediatric use

  Yes

  No

  N/A

• Pediatrics: Fall prevention precautions being followed

  Yes

  No

  N/A

• Pediatrics: Toys on unit are safe and free of hazards

  Yes

  No

  N/A

• Pediatrics: Staff aware of infant child abduction policy

  Yes

  No

  N/A

• Is this section free of additional findings (consider previous EOC report)?

  Yes

  No

  N/A

• Please describe other findings:

Chemical Hazards

• Staff know where and how to use the MSDS

  Yes

  No

  N/A

• Department is free of mercury

  Yes

  No

  N/A

• Spill kits available and staff know location

  Yes

  No

  N/A

• Is this section free of additional findings (consider previous EOC report)?

  Yes

  No

  N/A

• Please describe other findings:

Radiation Safety

• Radiation Safety program in place with Radiation Safety Officer

  Yes

  No

  N/A

• X-ray gowns are tested annually and results documented

  Yes

  No

  N/A

• Dosimeter reports are posted without ss number

  Yes

  No

  N/A

• Dosimeter badges replaced quarterly

  Yes

  No

  N/A

• Dosimeter mother / baby badges replaced monthly

  Yes

  No

  N/A

• Initial and annual C- Arm test by licensed medical physicist

  Yes

  No

  N/A

• Is this section free of additional findings (consider previous EOC report)?

  Yes

  No

  N/A

• Please describe other findings:

Laser Safety

• Laser Safety Program in place with Laser Safety Officer

  Yes

  No

  N/A

• Officer Name

• Is this section free of additional findings (consider previous EOC report)?

  Yes

  No

  N/A

• Please describe other findings:

• Fire pull stations are free from obstruction:

  Yes

  No

  N/A

• Fire pull stations are free from obstruction:

  Yes

  No

  N/A

• Fire Extinguishers checked monthly for placement and seal intact:

  Yes

  No

  N/A

• 3 foot clearance surrounding fire extinguishers

  Yes

  No

  N/A

• Exits are free from obstruction:

  Yes

  No

  N/A

• Evacuation Routes prominently displayed by elevators.

  Yes

  No

  N/A

• Exit signs operative and visible

  Yes

  No

  N/A

• Corridors, exits and doors unobstructed

  Yes

  No

  N/A

• Automatic magnetic fire doors release and shut securely:

  Yes

  No

  N/A

• No doors propped open

  Yes

  No

  N/A

• Staff demonstrates efficiency in Fire & Evacuation procedures and can explain R.A.C.E. & P.A.S.S.

  Yes

  No

  N/A

• Statement of Conditions is updated as required:

  Yes

  No

  N/A

• Employees interviewed know role in fire drill

  Yes

  No

  N/A

• Staff interviewed know location of nearest pull station / extinguisher

  Yes

  No

  N/A

• Is this section free of additional findings (consider previous EOC report)?

  Yes

  No

  N/A

• Please describe other findings:

• Staff follow procedure for placing malfunctioning equipment out of service

  Yes

  No

  N/A

• Staff reviewed knew procedure to notify biomed when needed

  Yes

  No

  N/A

• All equipment in good repair

  Yes

  No

  N/A

• List equipment not in good repair

• All biomedical equipment reviewed were bio-med checked as required

  Yes

  No

  N/A

• Is this section free of additional findings (consider previous EOC report)?

  Yes

  No

  N/A

• Please describe other findings:

Occurrence Reporting

• Staff reviewed know process to report equipment issues that harm patients

  Yes

  No

  N/A

• Is this section free of additional findings (consider previous EOC report)?

  Yes

  No

  N/A

• Please describe other findings:

Utilities

• Are personnel aware of whom to notify in the event of utility failures (Notify Plant Operations): Electrical

  Yes

  No

  N/A

• Are personnel aware of whom to notify in the event of utility failures (Notify Plant Operations): Medical gases

  Yes

  No

  N/A

• Medical gases: know where shut off valves are located

  Yes

  No

  N/A

• Are personnel aware of whom to notify in the event of utility failures (Notify Plant Operations): Heating/Air Conditioning

  Yes

  No

  N/A

• All electrical cords reviewed had hospital grade plugs in good repair:

  Yes

  No

  N/A

• List equipement that lacked hopsital grade plugs or were in poor condition:

• Is this section free of additional findings (consider previous EOC report)?

  Yes

  No

  N/A

• Please describe other findings:

Emergency Shut-Off valves

• All reviewed staff know location of the 02 shut off valve:

  Yes

  No

  N/A

• All staff reviewed know who can shut off gases:

  Yes

  No

  N/A

• Is this section free of additional findings (consider previous EOC report)?

  Yes

  No

  N/A

• Please describe other findings:

Medical Gases

• All medical gases reviewed are secured

  Yes

  No

  N/A

• Is this section free of additional findings (consider previous EOC report)?

  Yes

  No

  N/A

• Please describe other findings:

Staff

• Plan located in department and staff knows location and their role during a disaster

  Yes

  No

  N/A

• Staff interviewed knows that red outlets are for emergency power use

  Yes

  No

  N/A

• Bed availability is reported as required by the local authority for emergency management purposes during a disaster and during local drills

  Yes

  No

  N/A

• Nurse call system, code blue alarms, security panic buttons working

  Yes

  No

  N/A

• Staff interviewed were able to state the top three hazards identified in the HVA and their role

  Yes

  No

  N/A

• Staff interviewed knew emergency codes

  Yes

  No

  N/A

• Is this section free of additional findings (consider previous EOC report)?

  Yes

  No

  N/A

• Please describe other findings:

Physicians and LIP's

• Physicians and LIP’s interviewed knew codes and role during a disaster

  Yes

  No

  N/A

• Is this section free of additional findings (consider previous EOC report)?

  Yes

  No

  N/A

• Please describe other findings:

Contracted Staff (Environmental Services and Security)

• Contracted staff interviewed knew codes and role during a disaster

  Yes

  No

  N/A

• Is this section free of additional findings (consider previous EOC report)?

  Yes

  No

  N/A

• Please describe other findings:

Staff

• Employees reviewed wearing name badges

  Yes

  No

  N/A

• List employees not wearing name badges

• Staff reviewed know security policy :

  Yes

  No

  N/A

• Is this section free of additional findings (consider previous EOC report)?

  Yes

  No

  N/A

• Please describe other findings:

Physicians and Other LIPs

• LIP’s are wearing name badges

  Yes

  No

  N/A

• List LIP’s not wearing name badges

• Is this section free of additional findings (consider previous EOC report)?

  Yes

  No

  N/A

• Please describe other findings:

Vendors

• Vendors are wearing visitor badges

  Yes

  No

  N/A

• List vendors by name, company that are not wearing name badges

• Is this section free of additional findings (consider previous EOC report)?

  Yes

  No

  N/A

• Please describe other findings: