No items stored under sinks?

Equipment / Furniture:
* No broken equipment or furniture stored on the patient care units.
* 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:
* Equipment checked with up to date bio-med sticker.

Central Alarm Monitor:
* Logs accurate and complete.


Can staff locate medical gas zone shutoff valves.

Can Team Members code definitions.
* Red
* Yellow
* Orange
* Green
* Black
* Pink
* Silver
* Blue

Define PASS

Define RACE

Do Team Members know where nearest Extinguishers are?

Do Team Members know evacuation routes?

Do Team Members know where nearest pull stations are?


Appropriate storage of boxes and pt care items:
* Not directly on floor.
* 18" clearance from sprinkler head.
* Boxes stored on shelves close to floor must have solid bottom and high enough to not incur water damage from mopping.
* Volume of combustible material is not stored in large quantity as to create a fire hazard.

Oxygen or other combustible compressed gas cylinders are stored properly:
* Secured in floor stand, carrier or secured to the wall by a mount. (not laying on the floor or against wall)
* Limited to 12 E-cylinders per smoke compartment.
* Greater than 12 stored in a secured room.

Fire exits and hallways are cleared:
* Egress corridors must have 8ft clearance.
* Equipment in corridors must be actively accessed to be in use.

Fire alarm pull stations, fire extinguishers, medical gas shutoff valves are not blocked.

Fire extinguishers have been inspected monthly.

Maximum of 2-32 gallon trash cans in a 10x10 room. (unless fire rated)

Fire doors are not blocked or propped and when closed there is positive latching.

Exit signs are illuminated.

Evacuation route posted & current.

Everyone has ID badges and worn appropriately:
* Staff and Visitors

Ceiling tiles are in place, no cracks, holes, misaligned or visible stains.

Floors, ceilings, walls, and other surfaces intact and free from holes.

Nurse call lights working.

Are there any alarms operating appropriately?


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
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.