• Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel


1. Hand Hygiene

  • a. Towel dispensers full

  • b. Soap dispensers full

  • 1) product within expiration

  • 2) Soap dispensers damaged

  • c. Antiseptic gel dispensers full and functioning

  • 2) product within expiration date

  • Observe staff going in and out of rooms to see if hand hygiene is performed

2. Personal Protective Equipment

  • a. Readily available (gloves, masks, gowns, eye protection)

  • 1) appropriate and hospital approved masks available

  • b. Employee wearing appropriate barrier protection for patient (standard precautions)

  • c. Gloves are worn appropriately (worn only for direct patient care or while handling contaminated items)

  • d. Isolation Caddies Present

  • 1) isolation caddies stocked

  • 2) signage for isolation rooms appropriate

  • 3) employee using appropriate transmission based barrier precautions

  • 4) isolation education left on caddies

  • 5) caddies clean and free of inappropriate items

3. Sharps Container

  • a. Located in all areas where sharps are used, easily accessible

  • 1) appropriate height (no lower than 52 and no higher than 56)

  • b. Needles NOT recapped (check @ least 3 needle boxes)

  • C. Less than 3/4 full

4. Red Bags: Biomedical Waste Containers

  • a. Red bags or biomedical waste containers readily available

  • b. Only biomedical trash is placed in red bags or biomedical waste containers

  • c. Red bag/waste containers covered

5. General Information

  • a. Nurses station - counters un-cluttered, neat & clean

  • 1) drinks covered

  • 2) employee food on or in nurses station

  • 3) pneumatic tube station free of dust/dirt

  • 4) free of personal items bags, purses, jackets, coats

  • b. Underneath sink areas (not in pt. rooms) clear of any patient related supplies

  • c. Staff locker room floor clean, free of clutter, lockers dust free on top

  • d. Ceiling tiles are free of stained and intact

  • e. Storage units have solid bottoms

6. Linen Storage

  • a. Stored appropriately (in covered cart or enclosed cabinet)

  • b. Linen in hallway for distribution to patient rooms

  • 1) cart covered

  • 2) carts have solid bottoms

7. Soiled Linen

  • a. In appropriate blue bag linen hamper with lid closed (no more than 3/4 full)

8. Refrigerator (Medication & Pt. Nourishment)

  • a. Pt. food and medications stored in separate refrigerators

  • b. Pt. nourishments wrapped, dated, and labeled

  • c. Medications within expiration date, labeled

  • d. Pt. nourishments within expiration date

  • e. Refrigerator is clean/defrosted, and rubber seals are intact

  • f. No employee food in refrigerator

9. Refrigerator Log: (Medication & Pt. Nourishment)

  • a. Temperature recorded daily

  • b. If unit closed-noted per policy

10. Ice Machines

  • a. Drain, chute & exterior clean

  • b. Filter/fan exhaust clean-filter changed per policy

11. Code Carts

  • a. Clean

  • 1) storage bins free of dust

  • b. Locked

  • c. Checked daily

  • 1) noted when unit closed

  • d. Resuscitation bag/mask available

  • 1) stored in plastic dust cover

12. Medication Carts

  • a. Locked when unattended

  • b. Clean/uncluttered

  • 1) patient information on unattended cart

  • c. Free of personal items (food/drink/lipstick/etc.)

13. Corridors

  • a. Clear from equipment not immediately being used

  • b. Equipment being used is placed to one side (Pt. Care units - outside corridor)


14. Exam Rooms

  • a. Rooms clean and uncluttered

  • b. Counters clear of patient care items

  • c. Linen stored in cabinets

  • d. Patient care items > 12" from sink

III. Storage/Utility/Supply

15. Storage/Utility/Supply Room Doors Come To A Positive Latch

  • a. Utility/storage/pantry/ locker rooms kept closed

  • b. Clean utility room is clean and labeled

  • c. Dirty/ Soiled utility room is clean and labeled

16. Clean Supply/Storage/Utility Room

  • a. Sterile supplies intact & within expiration date

  • b. Patient supplies & stock at least "18 from ceiling

  • c. Patient supplies & stock at least "4 off floor

  • d. Clean storage/supply/utility area free of cardboard boxes and outside shipping cases/crates (checked locked areas/closets)

  • e. Common equipment cleaned and indicated (bagged & tagged)

  • f. Floors and bins clean and free of spills/stains/dust

IV. Medication Room

17. Medication Rooms

  • a. Clean and uncluttered

  • b. Patient supplies secured away from potential for contamination (sinks, floors)

  • c. Blood glucose/flex meter stored >12" from sink

  • d. Blood glucose/flex meter strips and reagent labeled with open date

  • e. Eyewash stations labeled and log present

V. General IP Practices/Staff Knowledge

Hand Hygiene

  • a. When should you wash your hands?

  • b. Are direct patient care givers allowed to wear nail enhancers? (Observe staff to see if any are)

  • 1) Observe for gel or chipped polish

  • c. What are two reasons you would use soap and water to wash your hands?

  • d. When can you use alcohol based gel to disinfect hands?

Isolation Patients

  • a. How do you know to place your patient on transmission based precautions?

  • b. When do you use standard-plus precautions?

  • c. How are you notified that your patient has a (+) culture with an MDRO?

  • d. What is the type of isolation you place your patient in if they have an MDRO?

  • e. Is a doctor's order needed to place a patient on isolation?

  • f. When do you educate pt., family, or significant others about the process of isolation?

  • g. What tool is used when education of pt., family, and significant others?

  • h. What 3 places should you document isolation? (1. IPOC 2. Patient Educ. 3. Isolation record)

  • i. How do you know if airborne isolation room is working?

  • j. Staff can verbalize and demonstrate location of isolation signs

  • k. What type of mask is used in airborne isolation room if you are just ruling out TB?

Infection Prevention General Knowledge

  • a. List your infection prevention practitioners

  • b. What can you say about infection prevention program on your unit?

  • c. Staff can locate IP policies

  • d. Staff can explain procedure for blood/body fluid exposure

  • e. Patient care areas are free of food, drinks, cosmetics

  • f. Unit/area free of personal lotion

  • g. What are standard precautions?

  • h. When do you use standard precautions?

  • i. Where is PPE kept?

  • b. Are direct caregivers allowed to wear nail enhances? (Observe)

VI. Low Level Disinfection Monitoring

  • a. Name a piece of non-critical item, and what would you do with a piece of non-critical equipment after using on a patient and before using on another patient?

  • b. How do you know if a bedside commode is "clean" or "dirty"?

  • c. What is the process of cleaning storage cabinets?

  • d. (Observe) Are staff cleaning non-critical equipment between patients

  • e. Can you tell me how equipment is cleaned that goes in and out of a patients room that is in isolation? (Also see if there is dedicated patient care equipment is being used)

  • g. Disinfectant contact time

VII. Environmental Services

  • a. General housekeeping closet in order, room/area neat

  • b. Housekeeping equipment clean & in good working condition

  • c. Cleaning supplies properly labeled & stored, closet clean & free of clutter

  • d. Floors clean, free of debris/spills

  • e. Goggles available for chemical admixture

  • f. Trash containers empty

  • g. Plastic liners in all waste containers

  • h. Hazardous waste properly handled

  • i. Furniture/appliances soil free

  • j. Curtains/drapes properly hung & clean

  • k. Mattresses are intact and clean

  • l. Walls free of spots and soil

  • m. Vents are dust free

  • n. No evidence of "high" dust

VIII. Pt. Rooms

  • a. Pt. room clean (bedside table, floor, uncluttered with linen, linen bags and trash < 3/4 full)

Misc. Items

  • a. Misc. Items of Concern

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.