• Audit Title

  • Conducted on

  • Prepared by

  • Location
  • Personnel


  • No items stored under sinks?

  • Equipment / Furniture:<br> * No broken equipment or furniture stored on the patient care units.<br> * Coverings are intact - no rips or repairs needed.

  • Potential safety hazards: Housekeeping & Maintenance carts & buckets are attended and locked. All fluids are labeled.

  • Laundry and trash chute accesses are locked.

  • Hazardous rooms are locked: EVS closets, supply closets, mechanical rooms and electrical panels.

  • Hazardous chemicals and flammable agents are labeled and stored properly.

  • Eyewash stations: Inspection tags are present and up to date.

  • Refrigerators: Contain only those items designed for that refrigerator (specimen, medications or patient food)

  • Refrigerators: If manually monitored, logs are complete. Both manual and temp track-documentation is present for actions taken to correct out of range temps.

  • Blanket, item warmers: Set to maintain temp of 130. Necessary logs completed including actions taken to out of range temperature readings.

  • Electrical safety: Use of hospital grade power strips, plugs & receptacles in good condition.

  • No outer shipping carton boxes in patient care areas.

  • No expired items.

  • Preventative Maintenance:<br> * Equipment checked with up to date bio-med sticker.

  • Central Alarm Monitor:<br> * Logs accurate and complete.


  • Can staff locate medical gas zone shutoff valves.

  • Can Team Members code definitions.<br> * Red<br> * Yellow<br> * Orange <br> * Green<br> * Black<br> * Pink<br> * Silver<br> * Blue

  • Define PASS

  • Define RACE<br>

  • Do Team Members know where nearest Extinguishers are?

  • Do Team Members know evacuation routes?

  • Do Team Members know where nearest pull stations are?


  • Greet the team with smiles and introductions.

  • Have a space designated for the team to conduct interviews and file reviews.

  • Promptly deliver materials required for review to the tracer team.

  • Any additional comments regarding positive or suboptimal issues observed during the tracer.

  • Surveyors Signature

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.