Information

  • Document No.

  • Audit Title

  • Site

  • Conducted on

  • Prepared by

  • Location

Previous Inspections

  • Items from previous inspections have been addressed ?

  • Notification

Safety

  • Work/Storage Areas <br>

  • Safety - Criteria

  • Notification

  • Other

  • Notification

Security

  • Appropriate identification used?

  • Criteria

  • Notification

  • Valuable items secured ?

  • Criteria

  • Notification

  • Other

  • Notification

Hazardous Materials/Waste

  • Hazardous Chemicals/Waste

  • Criteria

  • Notification

  • Lead Aprons

  • Criteria

  • Notification

  • Infectious Waste

  • Criteria

  • Notification

  • Other

  • Notification

Emergency Preparedness

  • Emergency numbers posted (6666 on the phones) ?

  • Notification

  • Other

  • Notification

Fire Safety

  • Fire Doors

  • Criteria

  • Field Assessment - Life Safety Interim Measures

  • Notification

  • Fire Exits

  • Criteria

  • Field Assessment - Life Safety Interim Measures

  • Notification

  • Sprinklers

  • Criteria

  • Field Assessment - Life Safety Interim Measures

  • Notification

  • Fire Alarm/Pull Station

  • Criteria

  • Field Assessment - Life Safety Interim Measures

  • Notification

  • Oxygen/Gas Cylinders

  • Criteria

  • Field Assessment - Life Safety Interim Measures

  • Notification

  • Electrical cords / strip outlets

  • Criteria

  • Field Assessment - Life Safety Interim Measures

  • Notification

  • Fire Extinguishers

  • Criteria

  • Field Assessment - Life Safety Interim Measures

  • Notification

  • Appliances<br>

  • Criteria

  • Field Assessment - Life Safety Interim Measures

  • Notification

  • Penetrations

  • Criteria

  • Field Assessment - Life Safety Interim Measures

  • Notification

  • Other

  • Field Assessment - Life Safety Interim Measures

  • Notification

Medical Equipment

  • Other

  • Notification

Physical Environment

  • Structural elements

  • Criteria

  • Notification

  • All items in storage are at least 4" off the floor

  • Notification

  • Other

  • Notification

Dietary / Nutrition

  • Refrigerators (for patient refrigerators only)

  • Criteria

  • Notification

  • Other

  • Notification

Infection Prevention

  • Area free of corrugated cardboard ?

  • Notification

  • Staff eating or drinking in designated areas only ?

  • Notification

  • Hand gel/soap dispensers

  • Criteria

  • Notification

  • Cubicle curtains are free of visible soil ?

  • Notification

  • Under sink storage clear (nothing allowed under sinks)?<br>

  • Notification

  • Dirty linen storage - room secured?

  • Notification

  • Linen covered in (inside or outside of the clean utility room)?

  • Notification

  • Medication refrigerators log

  • Criteria

  • Notification

  • High Level Disinfection - Daily and QC logs complete?

  • Notification

  • Test Strips in a closed bottle and inside a cabinet?

  • Notification

  • Other

  • Notification

Utilities

  • Fixtures in good condition

  • Criteria

  • Notification

  • Facility/Utility Rooms

  • Criteria

  • Notification

  • Med Gas Panel

  • Criteria

  • Notification

  • Electrical Panels

  • Criteria

  • Notification

  • Return / Supply air ducts in the ceiling clean (not covered with dust) ?

  • Notification

  • Appropriate pressure relationships.

  • Criteria

  • Notification

  • Other

  • Notification

Staff Knowledge

  • Reporting Accidents/Incidents ?

  • Notification

  • Back up/alternate communication systems ?

  • Notification

  • Code Pink ?

  • Notification

  • Code Gray ?

  • Notification

  • Hazardous Chemicals in the Area ?

  • Notification

  • Accessing SDSs ?

  • Notification

  • Code Violet ?

  • Notification

  • Code Red - RACE, PASS, Extinguisher/Fire Alarm Pull Station locations, Primary/Secondary Exits, Evacuation - horizontal/vertical ?

  • Notification

  • Oxygen Shut Off ?

  • Notification

  • Code Triage (Staff's role in a disaster - stand by and respond when/where needed) ?

  • Notification

  • Clinical Interventions for Equipment Failures ?

  • Notification

  • Utility Failure Procedures ?

  • Notification

  • Notification

  • How do you know if equipment is clean?

  • Notification

  • How and when to use the proper PPE?

  • Notification

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.