MMC Fire Drill

• Conducted on

  Date

• Prepared by

Site Information

• Quarter

  Q1 (Jan-Mar)

  Q2 (Apr-Jun)

  Q3 (Jul-Sep)

  Q4 (Oct-Dec)

• Building

  Select LL Bean Richards CFT Pav A Pav C/D NDF MGB Brighton Scarborough Surgery Center 100 Campus

  • LL Bean
  • Richards
  • CFT
  • Pav A
  • Pav C/D
  • NDF
  • MGB
  • Brighton
  • Scarborough Surgery Center
  • 100 Campus

• Shift

  1st Shift

  2nd Shift
Staff Knowledge

• 1. Staff has knowledge of fire plan for thei specific location and implemented plan in a timely fashion? Demonstrates knowledge of RACE?

  Yes

  No

  N/A

• 2. Staff has knowledge of fire plan for their specific location and implemented plan in a timely fashion? Demonstrates knowledge of PASS?

  Yes

  No

  N/A

• 3. Alarms, strobes, and paging (if available) worked properly?

  Yes

  No

  N/A

• 4. Fire doors/smoke barrier doors shut and latched, staff closed windows/doors, exits clear?

  Yes

  No

  N/A

• 5. Egress corridors clear of storage, hazardous materials/O2 cylinders?

  Yes

  No

  N/A

• 6. Staff demonstrated knowledge of fire extinguishers and fire alarm pull station locations?

  Yes

  No

  N/A

• 7. Presence of correct class fire extinguisher with current inspection tag?

  Yes

  No

  N/A

Scene Response

• 8. Staff loudly announces CODE RED to nearby team members?

  Yes

  No

  N/A

• 9. Staff informs response team of location, type, and status of fire/smoke/odor event?

  Yes

  No

  N/A

• 10. Staff made back-up phone call to 662-2345 (option 2) and gave more precise location?

  Yes

  No

  N/A

• 11. Staff has a method of accounting for each other and patients?

  Yes

  No

  N/A

• 12. Staff demonstrates knowledge of at least two evacuation/relocation routes?

  Yes

  No

  N/A

• 13. Knew the location of the O2 shut-off valve? (if applicable)

  Yes

  No

  N/A

• 14. "Senior Person" Charge Nurse, Nursing Administrator on call took charge and directed staff?

  Yes

  No

  N/A

• 15. Administration (Bramhall only) responded in a timely manner?

  Yes

  No

  N/A

• 16. Engineering (Bramhall only) responded in a timely manner?

  Yes

  No

  N/A

• 17. Security (Bramhall only) responded in a timely manner?

  Yes

  No

  N/A

• 18. Pulmonary (Bramhall only) responded in a timely manner?

  Yes

  No

  N/A

• 19. Floor above (Bramhall only) responded in a timely manner?

  Yes

  No

  N/A

• 20. Floor below (Bramhall only) responded in a timely manner?

  Yes

  No

  N/A

• 21. Sides (Bramhall only) responded in a timely manner?

  Yes

  No

  N/A

• 22. Switchboard responded in a timely manner and with appropriate information?

  Yes

  No

  N/A

Corrective Action Taken

• 23. Summary of ANY problems with staff knowledge, systems or response, indicate correcting action needed or performed, so indicate:

  Yes

  No

  N/A

Scoring:

• Enter any comments along with score " Passed or Failed "

  Pass

  Fail

  N/A

• Please enter your name then sign when assessment is completed.

  Sign