Title Page

  • Conducted on

  • Prepared by

  • Location

General safety

  • No staff food in refrigerator

  • No trip or slip hazards observed

  • Refrigerator temperature taken and patients food dated

  • Nothing else other than linen on linen cart

  • All equipment stored on one side of hallway

  • Top of linen cart covered

  • No equipment changing (plugged in)in hallway

  • Nothing parked in hallway longer than 30 minutes

Utility or storage room

  • Door to hallway closed not propped open

  • Top of linen cart covered when not in use

  • Signage posted for Oxygen storage area

  • Oxygen tank stored upright in a holder and sorted by full and empty tanks

Dirty utility holding room /sluice

  • Plumbed eyewash functional and checklist updated

  • No undersink storage

  • Biohazard waste contained

Clean Linen cupboard/room and waste cage

  • Windows to linen room closed and humidity controlled

  • Linen room /cupboard is dry

  • Linen cupboard locked and access controlled

  • Waste protected from access by pest . Access controlled system available

  • Plumbed eyewash provided and functional.checklist updated

  • Waste contained and not stacked on top of each other,and not placed Directly on the floor

Emergency Trolley

  • No expired supplies

  • Access controlled and maintained

  • No clutter on top

  • Daily check completed


  • No predrawn medication

  • No unsecured medication,sharps or syringes

  • No expired supplies

  • Discharged patients medication managed

  • Temperature logs completed with response to variances

  • Computerized pharmacy Portal logged off when not in use

  • Drawers or cabinet locked when in use

  • Door access controlled

  • Sterile water used for reconstitution

  • Pill crushers cleaned

  • Opened multi dose vials dated

  • No open single use vials

Point of care equipment

  • Lab quality assurance personnel process oversight evident

  • Operators trained and records available

  • Controls, strips and cartridges dated when opened

  • Glucometer cleaned

  • QC performed as per manufacturers instructions

Patient care

  • All low ceiling protrusions marked with mind your head signage

  • Mind your step signage on all staircases

  • Verbal orders records completed

  • Critical value records completed

  • Records for home medication

  • Patient review medication administration with staff

  • Time out for invasive procedures

  • Hand sanitizer is filled

  • PCI education record available and patients interViewed could demonstrate PCI procedure

  • Isolation precautions implemented

  • Confidentiality of medical records observed

  • Alarms are responded to

  • Emergency call lights and bells functional and within patients reach

  • PFE file present at patient care room and tools filled

  • Non ambulatory patients covered to maintain their dignity

  • Signage posted for fall Risk patients

  • Food delivered within the required timelines

  • Fall Risk assessment done and fall Risk patients wearing correct wrist band

  • All patients wearing correct identification band

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.