- 1-North Med/Surg
- 2-East Med/Surg
- Cardiac Rehab
- Cath Lab
- Clinical Engineering
- Diagnostic Imaging
- Emergency Room
- Outpatient Services
- Engineering Operations
- Foundation/Fund Development
- Home Health
- House Administrators
- Human Resources/Occup. Health
- Intensive Care Unit
- Resource Management
- Materials Management
- Patient Financial Services
- Patient Registration
- Pharmacy - Hospital
- Pharmacy - Lake Ozark
- Pharmacy - Camdenton
- Pharmacy - Osage Beach
- Public Relations
- Rehab/Cardiac Rehab - Osage Beach
- Rehab/Cardiac Rehab - Lake Ozark
- Rehab/Cardiac Rehab - Laurie
- Rehab/Cardiac Rehab - Eldon
- Rehab/Cardiac Rehab - Camdenton
- Respiratory Therapy
- Skilled Nursing Facility
- Social Services
- Speech Therapy
- Stepdown Unit
- Wound Care
Completed by (please enter your FULL NAME and TITLE):
01. If re-usable equipment (blood pressure cuffs, etc.) is used by more than one person or patient, is it sanitized between uses (or using DISPOSABLE equipment (cuffs)?
02. Are there any frayed, cracked or broken electrical cords in the department?
03. Are there any trip, slip or fall hazards in the department? (wet floors, cords across walking path, wrinkled up carpets/rugs, etc.)
04. Is the necessary Personal Protective Equipment (PPE) available for staff to do their jobs (masks, gloves, aprons, safety glasses, etc.)?
05. Is storage of patient care use items kept up off the floor at all times?
06. Is patient food/drink stored separately from employee food and drink?
07. Are all supplies (food, medication & equipment w/expiration dates) rotated back-to-front to prevent any outdated supplies?
08. Are all hallways and exit corridors around your department/area kept free of clutter, equipment and anything that may block the routes?
09. Is patient care equipment kept clean and sanitized between patient uses, if necessary?
10. Is alcohol-based hand sanitizer available for all staff where needed (not empty or missing)?
11. Check the alcohol hand sanitizer units. Are any of them within 6 of an electrical outlet or placed directly above an electrical outlet?
12. In patient care provider areas, are artificial nails being worn by staff OR are their natural nails longer then 1/4?
13. Are emergency pull cords in restrooms, locker rooms, etc., serving patients available and functional (not tied up to hand rail, cut too short, missing, etc.)?
14. Are there any damaged furnishings that could pose a safety risk (torn coverings on chairs/exam tables, broken chairs, desks, etc.) to staff, patients or visitors?
15. Are the necessary Material Safety Data Sheets available on the FISH for the departments hazardous materials?
16. If any corrosive chemicals or materials are used in the department, is there an emergency eyewash station within 15 seconds unobstructed access (no doors to open, etc.)?
17. Are all chemicals in your department properly labeled with the hazards they present to staff?
18. Are there more than 12 filled oxygen cylinders stored in the department?
19. Are full and empty oxygen (O2) cylinders stored separately to avoid a mixup of tanks?
20. Are waste receptacles clean and not leaking?
21. Are sharps containers full or overflowing?
22. Are dirty storage areas separated from clean supply storage areas?
23. Can staff identify the location of the nearest emergency fire alarm pull station?
24. Can staff verbalize the hospital extension to call to report a fire/smoke situation?
25. Can staff identify the location of the nearest portable fire extinguisher?
26. Can staff identify the location of the hospital emergency response plans?
27. Can staff identify the routes by which they would evacuate themselves, other staff, visitors or patient(s) during a fire situation?
28. Can staff describe the correct actions to take during a TORNADO situation affecting the organization?
29. Is a crash cart available and ready with all required equipment? Have all the required checks been completed (including having the defib unit plugged into the RED emergency power outlet)?
30. Is the crash cart blocking any fire extinguishers or fire pull stations?
31. Are medical gas shutoff valves clearly labeled as to which rooms/areas they supply and can staff verbalize who is responsible for shutting them down in an emergency?
32. Are flashlights available for emergency situations and do they work?
33. Can staff verbalize what type of waste can be discarded into the black containers located in patient care areas?
34. Can staff verbalize the process for reporting an employee injury (Quantros)?
35. Can staff describe how they would report an EVENT concerning a visitor, patient, physician or employee (using Quantros)?
36. There there any equipment (patient care, medical or general equipment) that is not operating as it was intended (broken, malfunctioning, missing, etc.)?
37. Has the function of the nurse call, duress alarms, or monitor alarms been tested to ensure they are functioning correctly?
38. Are the evacuation posters available, not covered up and up-to-date (do they still reflect the actual physical layout of your area, no construction changes, etc.)?
39. Are any fire exit doors on or near the department/unit blocked (by wheelchairs, equipment, beds, etc.)?
40. Do any fire doors (stairwell or auto closing) have ANYTHING posted on them (paper, decorations, flyers, etc.)?
41. Is trash in the department/area picked up on a regular enough basis to prevent excess buildup of trash (overflowing trash cans, smells, attracting insects, etc.)?
42. Are all sprinkler heads in the department/area clear and unblocked within 18 in all directions (see illustration below)?
43. Are all portable fire extinguishers nearest to the area checked (look at tag for date/initials for each month) each month, fully charged (look at gauge, should be in the green) AND not blocked by equipment (e.g., crash carts, beds, etc.)?
44. Look in any fire stairwells nearest the department. Is there anything stored within the fire stairwells?
45. Look at the illuminated fire exit signs in the hallways and fire exits. Are they all lit and clearly visible (not blocked by signs, equipment, etc.)?
46. Look at the fire pull stations in the hallways. Are they all clearly visible and not blocked (e.g., crash carts, beds, etc)?
47. Are all smoke detectors functional, unblocked and free or damage?
48. Are patient food and medication refrigerators checked daily and is the log up to date (no missing checks)?
49. Are blanket and fluid warmers checked daily and is the log up to date (no missing checks)?
50. Are crash cart / defibrillators checked daily and is the log up to date (no missing checks)?
51. Are there any stained, missing or broken ceiling tiles in the department/area?
52. Are there any damaged electrical outlet covers in the department/area?
53. Is there any evidence of leaking pipes, sinks, etc. in the department/area?
54. Are there any burnt out light bulbs in the department/area?
55. Are staff valuables secured properly (in lockers, offices, out of public view, no purses lying around)?
56. Are security sensitive areas properly secured (are locks functional, are proximity card readers working, doors shutting all the way and latching, no propped open doors, etc.)?
57. Is there any unsecured patient information lying around easily accessible to unauthorized individuals? (computer screens, printed facesheets, etc.)?
58. Are MEDICATION storage rooms/areas (this includes Pyxis machines) properly secured (are locks functional, are proximity card readers working, doors shutting all the way and latching, no propped open doors, etc.)? Any unsecured medications lying around?
59. Are staff wearing their hospital issued ID badges in a way that they are clearly visible to everyone they come in contact with (no name, title of photo covered up)?
Please report any additional safety issues or comments that you may have.