• Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by Rick Hacker, CHSP

  • Location
  • Personnel

  • 1-11-17 rev 3

General Safety

  • GS 1: No broken/damaged/unused equipment or furniture stored on the patient care units?<br> Coverings are intact - no rips or repairs needed?

  • GS 2: Are all electrical appliances (coffee makers, microwaves, radios, etc.) properly wired (3 prong/UL) & appear to be in good working condition?

  • GS 3: Is the floor clean & well maintained?

  • GS 4: Is extension cord/power tap policy being enforced?

  • GS 5: Hazardous rooms are locked: EVS closets, mechanical/electrical rooms & electrical panels?

  • GS 6: Linen and Linen Carts are Covered and carts have solid bottoms.


  • HAZ 1: Are the appropriate hazard signs posted (pregnancy, chemical, MRI, etc.)?

  • HAZ 2: Are hazardous chemicals and flammable agents labeled and stored properly?

  • HAZ 3: Are gas cylinders securely mounted and stored appropiately?

  • HAZ 4: Is the HMI (Hazardous Material Inventory) current Online?

  • HAZ 5: Can the staff locate the HMI?

  • HAZ 6: Are emergency eye washes & safety showers tested and inspection tags are present?

  • HAZ 7: Are eye washes & showers easily accessed?

  • HAZ 8: Are Hazardous Materials and drugs in proper waste stream?

  • HAZ 9: Are needles, syringes, sharps & glass disposed of properly?

  • HAZ 10: Biohazard waste:<br> 1. Discard in Red Bags with a biohazard symbol<br> 2. Not overfilled<br> 3. Covered containers<br> 4. Contains only biohazards waste, no trash<br> 5. Stored in a secure area

  • HAZ 11: Sharps Waste:<br> 1. Placed in punctured resistant sharps container with lid.<br> 2. Disposed of when 3/4 full or "full" indicator.<br> 3. Mounted appropriately.<br> 4. Stored in secure location.

  • HAZ 12: PPE available?

Life Safety/Fire Management

  • LS 1: Is the fire alarm system functioning (look for in-terminate lights) correctly?

  • LS 2: Appropriate storage<br> 1. Area does not exceed fire load with excessive combustible materials?<br> 2. Is 18" clearance from ceiling being maintained?

  • LS 3: Fire exits and hallways are cleared:<br> 1. Egress corridors must have 8' clearance.<br> 2. Equipment in corridors must be in use within 30 minutes to remain in corridor.

  • LS 4: Fire alarm pull stations, fire extinguishers, medical gas shutoff valves and electrical panels are <br> not blocked?

  • LS 5: Have fire extinguishers been inspected monthly? Annually?

  • LS 6: Are fire doors kept closed or magnetically held open?

  • LS 7: Fire doors are not blocked, wedged or propped and when closed is positive latching?

  • LS 8: Exit signs are illuminated and readily visible/undamaged?

  • LS 9: Are all sprinkler heads clean, in good shape and escutcheons tight/in place?

  • LS 10: Ceiling tiles are in place, no cracks, holes, misaligned or visible stains?

  • LS 11: Are stairways free of storage?

  • LS 12: Floors, ceilings, walls and other surfaces intact and free from holes, damage and soiling?

  • LS 13: Laundry chute accesses are latched?

  • LS 14: Is 36" clearance maintained around electrical panels?

Medical Equipment

  • ME 1: Are bio-medical equipment stickers on patient equipment current?


  • SEC 1: Are valuables secured (purses, expensive equipment, etc.)?

  • SEC 2: Confidential Patient Information: Cannot be overhead or seen by unauthorized persons:<br> 1. Computer terminals signed off when not in use.<br> 2. Patient information is not discussed in public areas.<br> 3. No patient information visible to unauthorized persons.

Utilities Management

  • UM 1: Are all electrical cords, plugs and switches in good order?

  • UM 2: Can the staff locate the medical zone shutoff valves?

  • UM 3: Wires neat and controlled with no trip hazards?


  • EX 1: Are manholes and vault covers secure?

  • EX 2: Are parking lots properly maintained to provide a safe driving & walking area?

  • EX 3: Is parking lot/crosswalks visible?

Infection Prevention

  • IP 1: Boxes stored on shelves close to floor must have solid bottom and high enough to not incur water damage?

Notes and Comments

  • Report conclusion including any other recommendations.

Sign Off

  • Your signature or reply (email) acknowledgement when the recommended corrective actions are completed.

  • Auditors Signature Rick Hacker, CHSP

  • Select date

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