Safety and Hazard Surveillance Survey - duplicate

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

STAFF KNOWLEDGE

• Staff able to demonstrate knowledge and skill in their role and expected participation in:

  Yes

  No

  N/A

• Infection control program?

  Yes

  No

  N/A

• What nationally recognized infection control standards are used in the facility?

  Yes

  No

  N/A

• Able to list when hand washing is required?

  Yes

  No

  N/A

• Able to state safe medication administration practice related to infection control?

  Yes

  No

  N/A

• Safety management program?

  Yes

  No

  N/A

• Security management program?

  Yes

  No

  N/A

• Hazardous materials and waste management program?

  Yes

  No

  N/A

• Staff able to locate MSDS for chemical used in area?

  Yes

  No

  N/A

• Emergency preparedness program?

  Yes

  No

  N/A

• Emergency procedures readily available and staff knowledgeable of location and contents?

  Yes

  No

  N/A

• Life safety program?

  Yes

  No

  N/A

• Staff aware of nearest fire pull, extinguisher and gas shut-off?

  Yes

  No

  N/A

• Demonstrate proper function and control of fire enunciator panel?

  Yes

  No

  N/A

• Utility management program?

  Yes

  No

  N/A

• Medical equipment management program?

  Yes

  No

  N/A

• How are equipment malfunctions handled?

  Yes

  No

  N/A

• How are you trained to operate equipment? What do you do if unsure of operation?

  Yes

  No

  N/A

• Staff able to demonstrate locating specific policies and procedures?

  Yes

  No

  N/A

OBSERVATION

• Infection Control

  Yes

  No

  N/A

• Employees able to state contact times for cleaning chemicals?

  Yes

  No

  N/A

• Sharps containers not more that 3/4 full?

  Yes

  No

  N/A

• All sharps containers secured to walls/carts?

  Yes

  No

  N/A

• All areas free from odors?

  Yes

  No

  N/A

• Bi-Monthly cleaning checklists complete for all areas: Pre-post, OR, Pain, GI, Med Rooms, Supply Rooms, SPD/Decontamination?

  Yes

  No

  N/A

• Temperature and humidity logs complete for OR, Sterile Supply, SPD and Decontamination?

  Yes

  No

  N/A

• Refrigerator log temperature checks up to date and complete with memory checked and cleared?

  Yes

  No

  N/A

• Medication refrigerators with no food items and proper storage of medications?

  Yes

  No

  N/A

• Solid surfaces present on the bottom of all storage carts?

  Yes

  No

  N/A

• Patient care items stored appropriately away from possible contaminants?

  Yes

  No

  N/A

• Fluid warmers with current temperature logs and no expired fluids (14 days)?

  Yes

  No

  N/A

• Tissue freezer with complete and up to date temperature checks, current AATB/FDA documentation, complete inventory and implant log?

  Yes

  No

  N/A

• Expiration dates present on all patient food refrigerator items?

  Yes

  No

  N/A

• No items stored under sinks?

  Yes

  No

  N/A

• Exposure control plan accessible and up-to-date?

  Yes

  No

  N/A

• Sinks in proper working condition?

  Yes

  No

  N/A

• Speak-Up education provided t all patients upon admission?

  Yes

  No

  N/A

• Ceiling tiles free of stains/dust?

  Yes

  No

  N/A

• All floors properly maintained?

  Yes

  No

  N/A

• PPE's available in all areas?

  Yes

  No

  N/A

• Red bags available in all areas?

  Yes

  No

  N/A

• Universal precautions observed at all times?

  Yes

  No

  N/A

• No food present in patient care areas?

  Yes

  No

  N/A

• Drink containers covered at all times?

  Yes

  No

  N/A

• Linen storage is covered at all times?

  Yes

  No

  N/A

• Clean to dirty flow is maintained and all dirty equipment covered for transport?

  Yes

  No

  N/A

• Air pressures maintained per standards?

  Yes

  No

  N/A

• Mattresses and pillows free of tears?

  Yes

  No

  N/A

• Proper hand washing observed?

  Yes

  No

  N/A

• Sterile Processing

  Yes

  No

  N/A

• All items cleaned per manufacturer guidelines?

  Yes

  No

  N/A

• Chemical indicator placed in each load with complete and accurate log of such?

  Yes

  No

  N/A

• BI is performed daily and with all implants?

  Yes

  No

  N/A

• Cidex logs complete with temperature checks and chemical indicator?

  Yes

  No

  N/A

• Washer and autoclave cleaning logs complete and accurate?

  Yes

  No

  N/A

• Cleaning agents are properly measured in sink?

  Yes

  No

  N/A

• Sinks are properly labeled?

  Yes

  No

  N/A

• Equipment

  Yes

  No

  N/A

• Equipment with current Biomed tags?

  Yes

  No

  N/A

• Electrical equipment in proper working condition with no frayed electrical cords?

  Yes

  No

  N/A

• Yes

  No

  N/A

• Yes

  No

  N/A

• Yes

  No

  N/A

• Safety

  Yes

  No

  N/A

• Staff appear to be working ergonomically safe?

  Yes

  No

  N/A

• All furniture in proper condition?

  Yes

  No

  N/A

• Weather radios on and functioning?

  Yes

  No

  N/A

• Walkie-Talkies plugged in and functioning properly?

  Yes

  No

  N/A

• Exit doors unobstructed?

  Yes

  No

  N/A

• Halls free of equipment? 8 foot clearance?

  Yes

  No

  N/A

• Exit signs visible with proper illumination?

  Yes

  No

  N/A

• Fire extinguishers checked monthly?

  Yes

  No

  N/A

• Fire extinguishers not blocked by equipment?

  Yes

  No

  N/A

• Fire drill logs up-to-date? 2 per shift per quarter.

  Yes

  No

  N/A

• Evacuation route maps posted in all areas?

  Yes

  No

  N/A

• Child-safe outlet protectors in place in all areas?

  Yes

  No

  N/A

• Spill kits present in areas of potential spills (Formaldehyde, blood/body fluids, Cidex)

  Yes

  No

  N/A

• No doors propped open/no wedges in use?

  Yes

  No

  N/A

• All doors positively latching?

  Yes

  No

  N/A

• No fire wall penetrations present?

  Yes

  No

  N/A

• 18" clearance from ceiling for all stored items?

  Yes

  No

  N/A

• No cardboard present in clean storage/restricted areas?

  Yes

  No

  N/A

• Emergency carts

  Yes

  No

  N/A

• Pre-op Crash Cart locked with current inventory, algorithms, daily and expiration date checklists?

  Yes

  No

  N/A

• Pre-op crash cart with full oxygen cylinder, portable suction and functioning defibrillator?

  Yes

  No

  N/A

• Pain Crash Cart locked with current inventory, algorithms, daily and expiration date checklists?

  Yes

  No

  N/A

• Broselow Cart locked with current algorithms, inventory and daily and expiration date checklists?

  Yes

  No

  N/A

• MH cart locked with current inventory and expiration date checklist?

  Yes

  No

  N/A

• Pain Crash Cart with full oxygen cylinder and portable suction?

  Yes

  No

  N/A

• Chest tube kit with current lock, inventory and expiration date checklist?

  Yes

  No

  N/A

• Emergency trach kit with current lock, inventory and expiration date checklist?

  Yes

  No

  N/A

• Emergency chest tube kit with current lock, inventory and expiration date checklist?

  Yes

  No

  N/A

• Gas cylinders clean, stored upright and labeled?

  Yes

  No

  N/A

• Empty gas cylinders removed when empty?

  Yes

  No

  N/A

• Eyewash stations tested daily and flushed weekly?

  Yes

  No

  N/A

• All chemicals stored and labeled appropriately? Stored at eye level or lower?

  Yes

  No

  N/A

• Flammable chemicals stored in fire cabinet?

  Yes

  No

  N/A

• Storage areas free of clutter and no itms stored on floor?

  Yes

  No

  N/A

• Cord management present in all areas; no tripping hazards?

  Yes

  No

  N/A

• Hot water temperature 120 degrees or less?

  Yes

  No

  N/A

• Corridor hand rails and bathroom grab bars intact and secure?

  Yes

  No

  N/A

• Patient call lights in reach of patients at all times?

  Yes

  No

  N/A

• Patient stretchers in lowest position when unattended?

  Yes

  No

  N/A

• Medication Safety

  Yes

  No

  N/A

• All medication areas have current expiration date checklists?

  Yes

  No

  N/A

• All medication areas clean with monthly cleaning checklists complete?

  Yes

  No

  N/A

• Supplies stored appropriate and with aseptic technique?

  Yes

  No

  N/A

• Medication refrigerator temperature logs complete with memory checked and cleared?

  Yes

  No

  N/A

• Medication refrigerators clean?

  Yes

  No

  N/A

• Normal saline vials are used one per patient?

  Yes

  No

  N/A

• RN identify patients using 2 patient identifiers each time a medication is administered?

  Yes

  No

  N/A

• Single use vials are used only one time?

  Yes

  No

  N/A

• All medications labeled appropriately?

  Yes

  No

  N/A

• 2 RN verification on labels of medications not administered by preparer?

  Yes

  No

  N/A

• Medications reviewed by entering and exiting personnel?

  Yes

  No

  N/A

• Medications on the sterile field/procedural area are labeled?

  Yes

  No

  N/A

• Unlabeled medications are discarded immediatley?

  Yes

  No

  N/A

• Medication preparation areas clean and free of debris?

  Yes

  No

  N/A

• All mediations stored in locked storage areas?

  Yes

  No

  N/A

• No expired mediations present?

  Yes

  No

  N/A

• Medications stored by route and different routes separated?

  Yes

  No

  N/A

• Look-alike/sound-alike practices observed?

  Yes

  No

  N/A

• CLIA Waived Tests

  Yes

  No

  N/A

• Blood glucose logs complete?

  Yes

  No

  N/A

• Owners manual present with machine?

  Yes

  No

  N/A

• Cleaning of machine documented with each use?

  Yes

  No

  N/A

• National Patient Safety Goals

  Yes

  No

  N/A

• 2 patient identifiers used when administering meds, labeling specimens, providing treatments?

  Yes

  No

  N/A

• Specimens are labeled in the presence of the patient?

  Yes

  No

  N/A

• Procedural sites are marked by MD with patient involvement?

  Yes

  No

  N/A

• Time-Outs are performed in all areas prior to the start of procedure?

  Yes

  No

  N/A

• Employees knowledgeable of Universal Protocol?

  Yes

  No

  N/A

• Yes

  No

  N/A