Title Page

  • Site conducted

  • Conducted on

  • Inspected by

  • Location
  • Department/Office
  • Dept. Director

Inspection Checklist


  • Are exit doors and stairwells clear? Main corridors and stairwell exits cannot be blocked by any means.

  • Are exit doors clearly marked "exit" and illuminated? Check for burned out bulbs. Is"No exit" not marked with "Not an exit" sign.

  • Are corridors and passageways free of obstruction? Corridors can have mobile items (wheels on them) that are emergency needed items and are in use.

  • Are pull stations or fire extinguishers unobstructed? There must be nothing obstructing access.

  • Have fire extinguishers been inspected & signed? Inspected monthly.

  • Is top of fire extinguishers more than 5 feet above floor.

  • Are fire doors propped/held open? Doorstops or homemade hold open devices are not allowed.

  • Are all materials, except for permanent cabinets, stored a minimum of 18 inches below sprinkler head? The distance between the sprinkler heads and stored items is 18” for sprinkled buildings.

  • Are sprinkler heads free of dust or foreign material/escutcheon are present & tight to the ceiling?

  • Are Sprinkler System Pipes used to support any other items?

  • Are storage rooms and equipment rooms free of clutter and unsafe conditions? Make sure items are not falling down. The storage areas have clear aisles to the back and are organized.

  • Staff know actions to take during a fire & fire equipment (extinguisher & pull station) locations. Tallies below.

  • Life safety question tallies: # Yes

  • Life safety question tallies: #No

  • Are holes and other openings in walls fire stopped/ Is I-Beams insulation intact?


  • Are showers clean and free of mildew, mold or discoloration? Is caulking, grout or other non-absorbable product intact and functional?

  • Is there evidence of smoking?

  • Are wet floors clearly marked to reduce slipping hazards? When floors are wet, does the staff put out “wet floor” signage?

  • Are the floors/hallways/rooms in good condition? – No broken/missing/lifting laminate on counters or walls, no lifting floor tiles or trip hazards? No peeling paint, wall damage, etc

  • Are ceiling tiles clean, stain free, and in good condition? Indicate where these stained tiles are located

  • Does all non-clinical electrical equipment have an initial electrical safety check inspection sticker? Indicate what equipment needs electrical safety inspections

  • Are all amp drawing appliances like refrigerators, freezers, coffee makers, space heaters, etc. plugged directly into the wall? Do not plug these types of devices into power outlet strips

  • Are Relocatable Power Taps (RPTs) in patient care vicinity & room permanently mounted

  • Are compressed gases stored properly? Compressed gases need to be chained to the wall or on a cart secured. Freestanding bottles are not allowed

  • Do the employees in the dept. have any safety concerns or suggestions? Forward all concerns to system safety officer

  • Are there any expired supplies on hand? Note findings below (include room, item, and exp. date).

  • Is the PBMC Safety Guidelines manual accessible and up to date? Online.


  • Are there any extension cords in this area? Remove these immediately.

  • Are all computer, equipment, telephone cords out of the way?

  • Are electrical cords free of cracks, fraying and cuts, not pinched? Note: include all IS workstations with movable parts.

  • Are all charging/electrical cords that are plugged into the wall connected to their electrical device? Power cords/charging cords for devices like laptops, cell phones, portable vital sign equipment, electric razors, etc. must be unplugged from the outlet when the device is not attached.

  • Are all mechanical, electrical, communications rooms clean with no storage? Indicate which rooms are not clean.

  • Do electrical panels have 3 feet of space all the way around them? Are they assessable?


  • Is there appropriate disposal of waste, including red, chemo, clear bag waste?

  • Are emergency eyewash and/or emergency showers free of obstructions and checked weekly?

  • Are all original and secondary chemical containers properly stored & labeled? Labeled with product name, hazardous ingredients and hazard warning.

  • Are chemicals stored separate from food or other clean items?

  • Is the dept. hazardous chemical inventory up to date and available to all staff? Dept. has an SDS for every chemical in the area.

  • Staff know where to find dept. SDS information. Tallies below.

  • SDS question tallies: # Yes

  • SDS question tallies collected. # No


  • Are staff's personal items properly secured? Check for purses, billfolds, money, keys, etc. visible.

  • Are all employees/medical staff wearing their ID badges in plain view? Tallies below.

  • ID Badge tallies: # Yes (Wearing)

  • ID Badge tallies: # No (Not wearing)

  • Are all patient medical records/patient information in a secured location? Check all department locations/cabinets to make sure medical records/patient information is not accessible to unauthorized personnel.

  • Are all mechanical, electrical, housekeeping, communications rooms locked? Indicate which rooms are not locked.


  • Does the equipment have any exposed wires? Check the cords and plugs for exposed wires, broken plugs, etc.

  • Does the equipment's cleanliness, paint, wiring, covers appear satisfactory?

  • Are all medical equipment inspection tags current? Check all equipment for expired inspection dates, including leased equipment.


  • Has the dept. call-back list been reviewed within the last 6 months and/or with any staffing changes? If not, update and distribute updated list to Switchboard, system safety officer, and department.

  • Staff know what a Code Triage is & their dept. duties? Staff tallies for disaster plan below.

  • Code Triage tallies: # Yes

  • Code Triage tallies: # No


  • Do staff know where the oxygen shut offs are and who is authorized to shut them off? Anyone can but must coordinate with nursing to ensure all oxygen-dependent patients have portable oxygen. Tallies below.

  • O2 question tallies: # Yes

  • O2 question tallies: # No

  • Are gloves, gowns, eyewear, and masks readily available?

  • Is the linen covered?

  • Is clean linen kept separate from the dirty linen disposal?

  • Are refrigerator temperatures checked and logged daily for medication and patient refrigerators? Is thermometer calibration current?

  • Are medications/needles/syringes kept in locked rooms/locations? Is the door/location closed tight?

  • Are medications and food kept in separate refrigerators?

  • Is medical waste kept in red biohazard bags or containers?

  • Were employees eating or drinking in designated areas only? Staff should not have food/drink in patient care areas

  • Are any patient contact items stored on the floor? Not allowed - infection control issue.

  • Are any food stuffs/bottled water jugs stored on the floor? Not allowed - infection control issue.

  • Are multidose vials dated when opened? Disgard open vial within 28 days of opening.

  • Are Betadine bottles dated when opened? Disgard open bottles within 30 days of opening.

  • Are all pill crushers and cutters clean in clinical areas?

  • Are all upholstered surfaces (i.e. exam tables, stretcher mats, pads, chairs, stools, etc.) intact? Any torn, cracked, ripped surfaces create an un-cleanable surface and infection control issue.

  • Are all casters on equipment in patient areas in good shape? Any rusty casters create an un-cleanable surface and infection control issue.

  • Are all opened packages of electrodes marked with their new expiration date? Keep electrodes in original package.


  • Were there additional deficiencies and/or finding (See note for details).

  • Surveyor Notes (please explain all failures)

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.