Information

  • Audit Title

  • Conducted on

  • Surveyor Signature

  • Staff Signature

ENVIRONMENT OF CARE

  • No items stored under sinks?

  • Equipment / Furniture:<br> * No broken equipment or furniture stored on the patient care units.<br> * Coverings are intact - no rips or repairs needed.

  • Potential safety hazards: Housekeeping & Maintenance carts & buckets are attended and locked. All fluids are labeled.

  • Laundry and trash chute accesses are locked.

  • Hazardous rooms are locked: EVS closets, supply closets, mechanical rooms and electrical panels.

  • Hazardous chemicals and flammable agents are labeled and stored properly.

  • Eyewash stations: Inspection tags are present and up to date.

  • Refrigerators: Contain only those items designed for that refrigerator (specimen, medications or patient food)

  • Refrigerators: If manually monitored, logs are complete. Both manual and temp track-documentation is present for actions taken to correct out of range temps.

  • Blanket, item warmers: Set to maintain temp of 130. Necessary logs completed including actions taken to out of range temperature readings.

  • Electrical safety: Use of hospital grade power strips, plugs & receptacles in good condition.

  • No outer shipping carton boxes in patient care areas.

  • No expired items.

  • Preventative Maintenance:<br> * Equipment checked with up to date bio-med sticker.

  • Central Alarm Monitor:<br> * Logs accurate and complete.

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EMERGENCY PREPAREDNESS

  • Can staff locate medical gas zone shutoff valves.

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INFORMATION MANAGEMENT

  • Confidential Patient Information:<br>Cannot be overheard or seen by unauthorized persons:<br> * Computer terminals signed off when not in use.<br> * Patient information is not discussed in public areas.<br> * Labels and PHI are obliterated before discarding in the trash.

  • No clipboards displayed as sign-in sheets when multiple patient names on the list.

  • If fax machine is in public area, patient information is quickly removed.

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LIFE SAFETY

  • Appropriate storage of boxes and pt care items:<br> * Not directly on floor.<br> * 18" clearance from sprinkler head.<br> * Boxes stored on shelves close to floor must have solid bottom and high enough to not incur water damage from mopping.<br> * Volume of combustible material is not stored in large quantity as to create a fire hazard.

  • Oxygen or other combustible compressed gas cylinders are stored properly:<br> * Secured in floor stand, carrier or secured to the wall by a mount. (not laying on the floor or against wall)<br> * Limited to 12 E-cylinders per smoke compartment.<br> * Greater than 12 stored in a secured room.

  • Fire exits and hallways are cleared:<br> * Egress corridors must have 8ft clearance.<br> * Equipment in corridors must be actively accessed to be in use.

  • Fire alarm pull stations, fire extinguishers, medical gas shutoff valves are not blocked.

  • Fire extinguishers have been inspected monthly.

  • Maximum of 2-32 gallon trash cans in a 10x10 room. (unless fire rated)

  • Fire doors are not blocked or propped and when closed there is positive latching.

  • Exit signs are illuminated.

  • Evacuation route posted & current.

  • Everyone has ID badges and worn appropriately:<br> * Staff and Visitors

  • Ceiling tiles are in place, no cracks, holes, misaligned or visible stains.

  • Floors, ceilings, walls, and other surfaces intact and free from holes.

  • Nurse call lights working.

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PATIENT SAFETY / NATIONAL PATIENT SAFETY GOALS

  • Are PSG posted on unit.

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STANDARD PERFORMANCE IMPROVEMENT

  • Are units quality improvement dashboards posted on unit.

  • Is unit's PI project data posted.

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PROVISION OF CARE TREATMENT AND SERVICES

  • Are there any alarms sounding that staff is not attending to in a timely manner.

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INFECTION PREVENTION

  • Food and drink in designated areas:<br> * No evidence of it in patient rooms/area, perches, hazardous chemical storage area, laboratory specimen area.

  • Hand Hygiene Products:<br> * No empty alcohol gel bottles<br> * No empty soap or paper towels<br> * No unapproved lotions

  • PPE:<br> * Readily available<br> * Clearly marked<br> * Worn correctly<br>

  • Patient food & drinks: No expired items.

  • Biohazard Waste:<br> * Discard in Red Bags with a biohazard symbol<br> * Not overfilled<br> * Covered when transported<br>

  • Soiled Linen: Properly stored and not overfilled.

  • Separation of clean vs. dirty supplies & equipment:<br> * Clearly marked<br> * Clean items if stored in soiled utility are covered & clearly marked

  • Patient care supplies:<br> * Not expired, damaged, soiled.

  • Linen and Linen Carts: Covered and carts have solid bottoms.

  • Sharps Waste:<br> * Placed in puncture resistant sharps container.<br> * Disposed of when 3/4 full or "full" indicator<br> * Mounted appropriately

  • General Cleanliness:<br> * Observe surfaces for high dust & residue, floors, stairwells, nutritional area, med prep areas, pt rooms & bathrooms<br> * No blood or bodily fluids

  • Air vents: Clean

  • All items in PT care area that are not disposable are able to be wiped down.

  • Curtains, drapes or blinds clean.

  • Negative and Positive air flow rooms function appropriately.

  • Ice machines clean.

  • Water fountains clean and functioning.

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MEDICATION MANAGEMENT

  • Medication rooms are clean and uncluttered.

  • Laminar flow hood is used for IV admixture when appropriate.

  • Visual inspection of medication containers: No Issues.

  • Area free of distractions.

  • Medication is appropriately labeled.<br> * Expiration dates, directions, etc..

  • All medications, needles and syringes are secured in locked cabinet or locked room or under constant surveillance.

  • Controlled substances stored to prevent diversion.

  • Medications stored appropriately to maintain stability.

  • Medications, formula, & solutions not expired beyond expiration date.

  • Opened multi-dose vials dated and initialed. Not expired.

  • Code Carts:<br> * Locked and marked with then first drug to expire.<br> * Checked per policy.<br> * Include defibrillator check.<br> * Extra locks kept secured.<br> * All supplies & drugs that are on the inventory list are on the cart.<br> *. Cart is clean.<br> *. O2 tank is >1/2 full

  • Syringes are labeled when in use.

  • Medication refrigerator: Only contain medications for current patients.

  • Breast Milk Refrigerators: Only contain milk for current patients.

  • Patient Bedside: <br> *. IV tubing is labeled per policy.<br> *. Medication is secured and labeled.<br> *. All solutions are labeled at the bedside.

  • Medication Carts: Doors and drawers are locked.

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RIGHTS AND RESPONSIBILITIES OF THE INDIVIDUAL

  • Patients and families properly informed of their rights.<br> *. Rights and Responsibilities statement

  • Family guides provided to all families on admissions.

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WAIVED TESTING / POINT OF CARE TESTING

  • Point of Care testing lab controls documented and control solution labeled & dated.<br> *. Reagents, i Stat analyzes, glucometers, GEMS

  • Point of Care Testing Quality Control:<br> *. Consistently and correctly documented<br> *. Dates missing initials<br> *. Performed by qualified person<br> *. Out of range is followed<br> *. Logged numbers match bottle ID numbers<br>

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DESCRIBE THE UNITS RESPONSE TO YOUR ARRIVAL

  • Greet the team with smiles and introductions.

  • Have a space designated for the team to conduct interviews and file reviews.

  • Promptly deliver materials required for review to the tracer team.

  • Any additional comments regarding positive or suboptimal issues observed during the tracer.

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Other Comments

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