• Audit Title

  • Document No.

  • Client / Site

  • 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.

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

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

  • Refrigerators: Temp-track accessible. Documentation is present for actions taken to correct out of range temps.

  • Blanket, item warmers: Set to maintain temp of 130.

  • 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.<br>* Random sampling of meds and items checked.

  • Temperature and humidity are monitored and maintained within accepted standards of practice; and if monitoring determined temperature or humidity levels were not within acceptable parameters, that corrective actions were performed in a timely manner to achieve acceptable levels.<br>20%-60% humidity <br>temperature

  • Preventative Maintenance:<br> * Random sampling of equipment checked with up to date bio-med sticker.


  • Staff can state RACE and PASS without prompting

  • Can staff locate medical gas zone shutoff valves.

  • Quarterly fire drill are documented and conducted at varying times of the date<br> *three years of drills are readily available


  • Confidential Patient Information:<br>Cannot be overheard or seen by unauthorized persons:<br> * Computer terminals signed off when not in use. <br> * Patient information is not discussed in public areas.<br> * Labels and PHI are obliterated before discarding in the trash.


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

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

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

  • Fire extinguishers have been inspected monthly.<br> * Random sampling extinguisher tags checked.

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

  • Exit signs are illuminated.

  • Everyone has ID badges and worn appropriately:<br> * 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.


  • Are units quality improvement dashboards posted on unit.

  • Is unit's PI project data posted and current

  • Staff can speak to current PI projects and goals


  • Food and drink only in designated areas:<br> * No evidence of it in patient areas, hazardous chemical storage area, laboratory specimen area, or any area where cross contamination may occur.

  • Hand Hygiene Products:<br> * No empty alcohol gel bottles<br> * No empty soap or paper towels<br> * No unapproved lotions<br> * No expired products

  • PPE:<br> * Readily available<br> * Clearly marked<br> * Worn correctly<br>

  • Patient food & drinks: No expired items.

  • Biohazard Waste:<br> * Discard in Red Bags with a biohazard symbol<br> * Not overfilled<br> * Covered when transported<br>

  • Soiled Linen: Properly stored and not overfilled.

  • Separation of clean vs. dirty supplies & equipment:<br> * Clearly marked<br> * Clean items if stored in soiled utility are covered & clearly marked

  • Patient care supplies:<br> * Not expired, damaged, soiled.

  • Linen and Linen Carts: Covered and carts have solid bottoms.

  • Sharps Waste:<br> * Placed in puncture resistant sharps container.<br> * Disposed of when 3/4 full or "full" indicator<br> * Mounted appropriately

  • General Cleanliness:<br> * Observe surfaces for high dust & residue, floors, stairwells, nutritional area, med prep areas, pt rooms & bathrooms<br> * No blood or bodily fluids

  • Air vents: Clean

  • All items in PT care area that are not disposable are able to be wiped down.

  • Items are disinfected after use<br>

  • Curtains, drapes or blinds clean.

  • Negative and Positive air flow rooms function appropriately.

  • Ice machines clean. <br>*log available and up to date


  • Medication rooms are clean and uncluttered.

  • Visual inspection of medication containers: No Issues.

  • Area free of distractions.

  • Medication is appropriately labeled.<br> * Medication name<br> * Medication strength<br> * Initials of person drawing up medication<br> * Date and time of draw<br> * Expiration date and time(one hour from draw)<br><br>

  • All medications, needles and syringes are secured in locked cabinet or locked room or under constant surveillance.

  • Medications stored appropriately to maintain stability.

  • Medications & solutions not expired beyond expiration date.

  • Staff check ID band and allergies prior to administering medications.

  • Opened multi-dose vials dated and initialed. Not expired.

  • Code Carts:<br> * Locked and marked with then first drug to expire.<br> * Checked per policy.<br> * Include defibrillator check.<br> * Extra locks kept secured.<br> * All supplies & drugs that are on the inventory list are on the cart.<br> *. Cart is clean.<br> *. O2 tank is >1/2 full

  • Patient Bedside: <br> *. IV tubing is labeled per policy.<br> *. Medication is secured and labeled.<br> *. All solutions are labeled at the bedside.

  • Medication Carts: Doors and drawers are locked.


  • Patients and families properly informed of their rights.<br> *Rights and Responsibilities statement

  • Provide the patient or, the patient’s representative was provided with written information concerning its policies on advance directives, including a description of applicable State health and safety laws and, if requested, official State advance directive forms.<br>


  • Point of Care testing lab controls documented and control solution labeled & dated.<br> *expiration and open dates

  • Training for staff that are completing waived testing is available.


  • A pre-procedure verification process to make sure all relevant documents (including the patient’s signed informed consent) and related information are available, correctly identified, match the patient, and are consistent with the procedure the patient and the ASC’s clinical staff expect to be performed;

  • Site marking conducted according to policy

  • Time out conducted according to policy


  • Manager attends survey

  • Able to promptly deliver requested logs and materials required for review.

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

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.