Select date

Rating Scale (1. Immediately) (2. 24-48 Hours) (3. 15 Days) (4. 30 Days)

Fire Safety

Are exit doors and stairwells clear? (Main, corridor, and stairwell exits cannot be blocked by any means.) (Rating 1)

Are exit doors clearly marked exit and illuminated? (Check for burned out bulbs.) (Rating 2)

Do fire doors latch properly? (Close fire door to see if they latch properly and see that there is no gap 1/8 inch in the middle.) (Rating 2)

Are corridors and passageways free of obstruction? (The corridors can have mobile items (wheels on them) that are emergency needed items and are in use.) (Rating 2)

Are pull stations or fire extinguishers unobstructed? (There must be nothing to obstruct access.) (Rating 1)

Are doors not propped/held open? (Doorstops or homemade held open devices are not allowed while no one is in the area. They are allowed as long as someone is in the area but once they are out of the area, it must be removed. Tape is not allowed over any corridor doors. Any of these items must be removed immediately.) (Rating 1)

Are all materials stored a minimum of 18 inches from sprinkler deflectors? (The distance between the sprinkler deflector and stored items 18" for sprinkled buildings.) (Rating 2)

Are storage rooms and equipment rooms free of clutter and unsafe conditions? (Make sure that items are not falling down or overstocked. This is a judgment call.) (Rating 3)

Safety Management

Is area free from evidence of smoking? (Rating 1)

Are the floors/hallways in good condition? (Rating 3)

Are the walls not needing paint repair? (Rating 4)

Are any cables or wires not exposed? (Rating 4)

Are ceiling tiles clean, stain free, and in good condition? ( Indicate where these bad tiles are located in the comments.) (Rating 3)

Are heavy items stored at low levels or mid levels in storage? (Make sure the heavy items are stored at waist level or lower shelves.) (Rating 3)

Are general areas clean and free of clutter? (Rating 2)

Are compressed gases stored properly? (Compressed gases need to be chained to the wall or on a cart secured. Freestanding bottles are not allowed.) (Rating 1)


Are 2 prong extension cords removed from this area? (These are the household type extension cords. Remove these immediately.) (Rating 1)

Are telephone cords out of the way? (Rating 3)

Are all mechanical, electrical, janitorial, communications rooms are clean with and with no storage? (Indicate which rooms are not clean that are itemized here.) (Rating 3)

Infection Control

Are gloves, gowns, eyewear, and masks readily available? (Rating 1)

Is clean linen covered? (rating 1)

Is clean linen kept separate from the dirty linen disposal? (rating 1)

Are refrigerator logs maintained and up to date in medicine and patient refrigerator? (Rating 1)

Are medicines and food kept in separate refrigerator? (Rating 1)

Are needles boxes under 2/3 full? (Rating 2)

We're employees eating or drinking in designated areas only? (Staff should not have food/drink in patient care areas.) (Rating 1)

Are cleaning products the only things located under sinks? (These are the only items allowed under sink.) (Ratings 2)

Hazardous Materials and Waste

Are secondary chemical containers labeled with product name, hazard label? (Indicate any chemical that is in a container other than the original container.) (Rating 2)

Are chemicals stored separate from food or other clean items? (Rating 1)

Is the Hazardous Chemical Inventory (MSDS) adequate and available to all employees? (The Hazardous Chemical Inventory is located on any computer in the hospital on the intranet site under the HazSoft App. Their is a hard copy of all Material Safety Data Sheets in the Emergency Department EMS room. Buildings that are separated from the hospital will maintain a hard copy of all Material Safety Data Sheets on site.) (Rating 2)

Are appropriate procedures, instructions, or directions available for obtaining MSDS? (There should be instructions within the department to access the MSDS.) (Rating 3)


Is staffs personal items properly secured? (Check for purses, billfolds, money, keys, etc left out for you to take.) (Rating 2)

Are all employees wearing their ID badges in plain view? (Rating 1)

Are all mechanical, electrical, janitorial, communications rooms locked? (Indicate which rooms are not locked and itemize here.) (Rating 1)

Are medications kept in locked rooms or cabinets? (Rating 1)

Medical Equipment

Does equipment not have any exposed wires? (Check the plug for exposed wires.) (Rating 1)

Are all medical equipment tags current? ( Check all equipment for expiration dates. Leased equipment must also have been initially inspected.) (Rating 2)

Does the equipment's cleanliness, paint, wiring, and covers appear satisfactory? (Rating 3)

Staff Knowledge

Staff members know what is a Code Yellow?

Staff members know the EOC Committee? (They can describe the safety committee in some way.)

Do Staff members know how to report defective equipment? (Medical or utility)

Do Staff members know how to report accidents and or injuries?

Do staff members know what is a Code Gray and what to due?

Are staff knowledgeable regarding Oxygen cut off valves? (Who is authorized to cut off gases.) Charge Nurse or Nurse Supervisor

Do staff members know How to obtain Material Safety Data Sheets using the HazSoft APP on the computer and where the MSDS books are located?

Do staff know where the oxygen cut off valves are located? (Can show you where they are located on the wall.)

Rating Scale (1. Immediately) (2. 24-48 Hours) (3. 15 Days) (4. 30 Days)

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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.