Safety Unit Champion Hazard Survey

• Conducted on

  Date

• Unit Safety Champion

• Performed By

• Building

• Department

Patient Management

• Staff demonstrate safe patient re-positioning?

  Yes

  No

  N/A

• Staff demonstrate safe patient transfers?

  Yes

  No

  N/A

• Staff demonstrate safe patient transfer to a different level?

  Yes

  No

  N/A

• Staff have been trained on the use of patient lifting equipment?

  Yes

  No

  N/A

• Staff have access to re-positioning sheets and gait belts?

  Yes

  No

  N/A

MAINTENANCE

• All lighting is functional?

  Yes

  No

  N/A

• Ceiling tiles are clean and intact?

  Yes

  No

  N/A

• No visible signs of plumbing leaks? No water found under the sinks, around toilets or around ice machines.

  Yes

  No

  N/A

• Flooring is free of trip hazards?

  Yes

  No

  N/A

• Wet floor signs are posted properly?

  Yes

  No

  N/A

• All doors open and close properly?

  Yes

  No

  N/A

• All appliances are in working order?

  Yes

  No

  N/A

• All food is covered, dated and labeled?

  Yes

  No

  N/A

Security

• All staff have name badges visible above the waist?

  Yes

  No

  N/A

• Staff knows how to contact security?

  Yes

  No

  N/A

• Emergency contact numbers are present on all phones?

  Yes

  No

  N/A

• Security alarms are functioning properly? Including panic devices, HUGS alarms, door prop alarms.

  Yes

  No

  N/A

• Intercom system can be heard in all areas?

  Yes

  No

  N/A

• All locks are working properly?

  Yes

  No

  N/A

• Staff personal property securely locked away?<br>

  Yes

  No

  N/A

• Staff have access to parking lot escorts?

  Yes

  No

  N/A

• Security patrols units and parking lots on a regular basis?

  Yes

  No

  N/A

Electrical

• All electrical cords are in good condition?

  Yes

  No

  N/A

• Extension cords are not used in place of permanently installed fixed wiring?

  Yes

  No

  N/A

• A lock-out/tag-out procedure is in place and staff is trained regarding these procedures?

  Yes

  No

  N/A

• Relocatable power taps are of the appropriate type?

  Yes

  No

  N/A

Storage Areas

• Aisles are clear and the floor is clean?

  Yes

  No

  N/A

• Shelves and racks are of adequate strength and are secured?

  Yes

  No

  N/A

• Heavy items stored on shelves between the knee and shoulder height?

  Yes

  No

  N/A

• No material over 30 lbs. stored at more than five feet above floor?

  Yes

  No

  N/A

• Sharp edges are identified and eliminated?

  Yes

  No

  N/A

• Bump hazards are eliminated?

  Yes

  No

  N/A

• Falling object hazards are eliminated?

  Yes

  No

  N/A

• Employee locker rooms are clear and free of hazards?

  Yes

  No

  N/A

Exits

• Exit routes are unobstructed?

  Yes

  No

  N/A

• Exits are clearly marked with illuminated signs?

  Yes

  No

  N/A

• Emergency lighting provided for all occupied areas and tested?

  Yes

  No

  N/A

• Emergency evacuation plans posted?

  Yes

  No

  N/A

• All doors in exit path are kept closed?

  Yes

  No

  N/A

• Lighting is adequate?<br>

  Yes

  No

  N/A

• Adequate number of exits are provided?

  Yes

  No

  N/A

• Exit doors are operable in the path of exit travel without the use of a key or any special knowledge?

  Yes

  No

  N/A

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