Building Name


Departments in this building have completed the monthly safety rounds and have submitted these to the safety officer for this quarter


Staff quickly respond to patient call lights. Pull cords are no more than 6" off the floor. Test a patient alarm. Record the time for staff to respond. Reset the system to normal use after the test

Staff know where lifting equipment is located and how to properly know how to use it. (Gait belts, Hoyer Lifts, ect)

Ask staff what they would do if the injured themselves, needle stick, slip and fall, back injury, or other injury

Housekeeping closets are locked (Randomly select a room to check)

Soiled utility rooms are locked. (Randomly select a room to check)

Clean utility rooms are locked (Randomly select a room to check)

Oxygen storage rooms are locked (Randomly select a room to check)

There are no more than 12 oxygen tanks stored together (Randomly select a room to check)

The empty and full oxygen tanks stored in separate racks (Randomly select a room to check)

Medication rooms are locked (Randomly select a room to check)

Utility closets in public areas are locked (Randomly select a room to check)

Bio-Hazard room is secured at all times


Medical Imagining staff members are wearing dosimeters


Ask if staff feel safe working at MCMC. How could they feel more safe?

All staff members are wearing hospital identification badges

Doors that should be locked are locked to control access into your department from patients and visitors

Childproof protective outlet covers are located in outlets in lobbies, hallways, and public gathering points

Medical records cannot be seen from the "public's" point of view at the workstations/nurse's station


Does staff know where the closest eyewash station is located? Have them describe the steps to use it appropriately. Verify the weekly flow test (located in EVS office)

Staff know the location of hard copies of MSDS as well as how to access the MSDS database from the Pulse


Ask staff the wet dwell time to the:
green top wipes (10 mins)
red top wipes (1 min)

Verify that negative and positive pressure rooms are functioning according to the monitors on the wall as well as a manual test is conducted on each applicable room.

Linen and supply carts have a plastic liner on the bottom of the cart to prevent dust and splash up from mopping

Containers or equipment in the "ready position" is still protected by its protective coverings. (Glide Scope Blades,etc...) (IC.02.02.01)

Areas are clean, sanitary, and free from reoccurring offensive odors. These include lighting, vents, surfaces, walls, ceilings, and equipment


Does staff know where to access emergency policies? Ask them to find two policies, one must be Code Purple

Staff know there role during a Plan F (Fire Response) formally Code Red. Staff know RACE and PASS

Staff know what their role would be during a Plan WEATHER (Severe Weather)

Staff know their role during a Code Purple. Ensure they know not to leave their guarded area until annAll Clear is paged overhead

Staff know their role during a Code Blue

Staff know what to do during a Code Yellow. What if they received the bomb threat

Staff know their role during a Code Strong. Have them describe examples when a code strong would be called


Hallways are free from all obstructions. This does NOT include crash carts, isolation carts, and equipment in use (this means accessed at least every 30 minutes or more often)

Stored items are more than 18" from the bottom of the ceiling in any room

Loose papers on door shall not exceed 10% of the door's overall surface area

Fire extinguishers and pull stations are not blocked at all times

Emergency Exit signs are clearly visible and working properly (evenly illuminated)

Fire doors are not blocked from shutting and latching properly

Doors are not wedged open

Medical gas shut offs are properly labeled and clear of obstructions

Documentation is provided and logged to provide proof of the fire alarm and suppression systems. (Add info on the specific requirements, sprinklers, kitchen hood,....)


Biomedical Inspection Labels are placed on equipment inspected from BioMed (check 5 pieces of equipment).

Temperatures in refrigerators are being documented according to departmental policies.

Equipment that emits heat has appropriate signage to reflect the hazard.

Blanket warmers are set within range of the warmer.

Fluid warmer temperatures are set to achieve a safe range.


Ventilation and temperature of rooms are appropriate for the designated use.

Internal walls, doors, windows, ceilings, cabinetry, floors, and ect. are in good condition

External walls, doors, windows, ceilings, cabinetry, floors, and ect. are in good condition

All shut off points for utilities are labeled and properly displayed on a facility map. (This map would be located in the EVS office)


Any other concerns during this inspection?

Add additional photos
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Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.