• Date Conducted:

  • Prepared by:

  • Audited by:

2.0 Patient Exam Rooms

  • 2.1. Floor and walls clean?

  • 2.2. Cubicle curtains unsoiled and free of tears?

  • 2.3. Exam table/bed is clean free of dust, rust, tapes and tape residues.

  • 2.4. Sink is clean and no supplies found within Splash Zone of sink in the absence of a splash guard.

  • 2.7. Gloves, PPE available?

  • 2.8. No food or drink in patient care areas?

  • 2.9. Vent grill is dirt free?

  • 2.10. Wedges for positioning cleaned and disinfected after every patient use?<br>

  • 2.11. Drawers well organized and clean?

  • 2.12. Working surfaces are clean?

  • 2.13. Equipment decontamination done?

  • 2.14. Mattress pad is without tears or puncture holes?

  • 2.15. Plants not present in clinical areas?

  • 2.17. All surfaces on the MRI table (inside the magnet bore, magnet gantry and MRI coils) is clean?

  • 2.19. Is equipment properly cleaned per protocol/ manufacturer's recommendation?

3.0 Waste Management

  • 3.1. Waste containers clean, operational and in good condition?

  • 3.3. Contaminated instruments or disposables placed on designated area not mixed with clean items?

  • 3.4. Regulated medical waste discarded appropriately & clearly segregated?

  • 3.6. Sharp containers secured, labeled, & no more than 2/3 full?

  • 3.9. Staff aware not to bend, recap or remove contaminated needle or sharps unless absolutely necessary?

4.0 Medications/ Items

  • 4.1. No outdated IV solutions, items and meds?

  • 4.2. Open vials dated and times as per policy?

  • 4.4. Out of date sterile supplies are not present?

5.0. Utility and Storage Room

  • 5.1. Floors and walls clean?

  • 5.2. Horizontal and vertical surfaces are clean?

  • 5.3. Adequate separation of clean and soiled?

  • 5.4. Bottom shelf is solid?

  • 5.5. No supplies stored 8-10" from the floor?

  • 5.6. No supplies stored touching the 18" from the ceiling?

  • 5.7. No supplies stored in the dirty utility room?

  • 5.8 Soiled linen is bagged accordingly?

6.0. Chemical Safety

  • 6.3. All containers labelled correctly?

  • 6.4. Unused substances disposed of?

  • 6.7. If required is PPE available?

  • 6.8. Are eye washes and showers easily accessed?

7.0. Corridors/ Hallways/ Environment

  • 7.1. Furniture is clean and in a good state?

  • 7.2. The wall is clean and dust free?

  • 7.3. Free of obstruction and equipment?

  • 7.4. Reception area is clean and work surface clean and free from clutter?

  • 7.5. Horizontal surfaces free from dust?

Staff Knowledge on Infection Prevention

  • Staff able to articulate the care for instruments at point of care prior to transport to SPD

  • Staff able to articulate how an isolation patient is identified & manage

Additional Comments

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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.