• Quarter # and Location

  • Conducted on

  • Prepared by

  • Personnel Assisting


  • 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:<br>green top wipes (10 mins)<br>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


  • Please Sign to Complete

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