Nuclear Medicine Internal Audit

Staff know where to find IP policies, where to find isolation precautions in WakeOne, process for monitoring airflow, etc.

Nursing Station (no food/uncovered drinks, only hospital-approved lotions, sinks are identified appropriately, etc.

Procedure Rooms (Environment is clean/in good repair, all items are within expiration dates, only appropriate items are stored under sinks, etc.)

Par Stock (No cardboard, storage at least 8” off floor, no expired products, etc)

Linen (Clean line is covered, no items stored with linen, plastic bags are available for wet linen, etc.)

Medications (Items are not expired, rooms are clean)

Waiting Rooms (Water fountains are clean, room is clean and in good repair)

Laundry (Work surfaces are clean, instructions are posted)

Isolation Precautions (Isolation signs posted on pts door, PPE cart is outside room, PPE cart is stocked)

Patient/Exam Rooms (Sharps are not over-filled, sinks are labeled as hand washing or non hand washing, environment is clean)

Nourishment Rooms (Refrigerator/freezer is clean, no expired products, no staff food in patient refrigerator)

Clean Utility Room (No dirty linen, environment is clean, storage is at least 8” off floor)

Soiled Utility Room (No clean items, sinks are not obstructed, PPE is available)

Equipment/Instruments (Equipment is labeled as clean or dirty, no medical equipment on the floor, equipment is clean)

Restrooms (Restrooms are clean, sinks are working properly, toilets are secure to the wall)

Other

Emergency Equipment is plugged into correct outlets.

Call bell reaction time less than 60 seconds.

Glucometer devices without blood

Sharps containers are below fill line

All stored linen is covered.

Glucometer control is dated with 90 day exp

glucometer strips are dated with 6 month exp

EKG are dates with 30 day exp.

No corrugated cardboard.

Essential equipment on one side of the hall.

Eye wash bottles are in date.

Screening for falls.

Name badge worn above the waist?

Radiation Badges worn correctly?