• Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

Fire/Life Safety

  • Fire extinguishers readily accessible/unobstructed

  • Fire extinguishers tagged and inspected monthly

  • Travel distance to fire extinguishers < or = 75'

  • Doors in egress corridor self-closing or automatic closing

  • Doors not propped open

  • Doors in egress corridor positive latching

  • Fire doors free of obstructions to allow proper closing

  • Ceiling tiles in place/not damaged/stained

  • Evacuation routes posted and current

  • Hall is free of obstructions that could block free movement

  • Equipment located on one side of the aisle

  • Nurse servers/charting surfaces kept up/secure when not in use

  • Exit stairwells/passageways free of obstructions

  • Exit signs:<br> * Adequately illuminated/marked<br> * Readily visible from any direction of access<br> * Provided with a directional indicator that shows direction of travel when nearest exit is not apparent

  • Linen/waste chute doors self-closing/positive latching

  • Pull boxes well marked and unobstructed

  • Alcohol-based hand sanitizer dispensers installed per codes (>6" from electrical outlet and not directly above an electrical outlet).

  • Smoking policy enforced

Electrical Safety

  • Equipment is in good working order with no visible signs of electrical safety hazards

  • Electrical safety checks performed by Biomed/Facilities as required

  • Electrical plugs and cords in good repair

  • Electrical extension cords are not in use except where permitted

  • Use of portable heating devices prohibited in patient treatment areas; except physician- ordered treatment devices

  • Portable heating devices prohibited in employee areas except when approved by engineering (non sleeping staff and employee areas and heating elements <212 deg.).

  • Blanket warmers safely used (correct temperature setting <=130 deg, not overloaded, adequate clearance on bottom rack, etc.)

Hazardous Chemicals/Hazardous Waste

  • Regulated Medical Waste properly handled, segregated, stored

  • Chemotherapy drugs properly handled, stored, and disposed

  • Sharps containers available and not overflowing

  • Acids, solvents, and other chemicals safely handled, stored

  • Personal protective equipment (gloves, gowns, aprons, safety glasses, masks, etc.) available, properly stored.

  • Containers properly labeled (identity and hazard warnings)

  • When corrosive chemicals are present, is there a portable eyewash stations available (within 15 second access unobstructed), operable, and tested/checked weekly

  • Access to MSDSs (SDS) via Citrix or security

  • Compressed gas tanks properly stored and secured

  • Oxygen storage limited to 12 e-cylinders (unless 1 hr. fire rated room).

General Safety

  • Storage areas neat and orderly, free of clutter

  • Storage greater than 18" from fire sprinkler heads

  • Carts, stretchers, IV poles, chairs, etc., in good condition

  • Walking/climbing surfaces (floors, stairs, etc.) clear/safe with no trip, slip or fall hazards (wet floors, cords across walking surfaces, wrinkled up carpets/rugs, etc.).

  • Wet floor signs available and used

  • Handrails in halls present, accessible and properly secured

  • Machine guarding in compliance


  • Employees/staff wearing ID badges per policy

  • Panic alarms present/ functioning

  • Rooms/offices secure when unattended

  • Property/valuables secure and out of plain view

  • Emergency access to all locked and occupied spaces

Patient Care Environment (EC.02.06.01)

  • Interior spaces safe and suitable for patient care/treatment/services

  • Lighting is suitable for care, treatment, and services

  • Ventilation, temperature/humidity levels suitable for patient care

  • Areas clean, sanitary and free of offensive odors

  • Furnishings and equipment safe and in good repair

Emergency Preparedness

  • Staff can identify the location of the nearest emergency fire alarm pull station.

  • Staff can identify the location of their nearest exit and where they discharge the building

  • Staff can identify the location of their nearest fire extinguisher

  • Staff are familiar with RACE and PASS for fire reesponse

  • Staff can verbalized the hospital extension to call to report a fire/smoke situation

  • Staff can identify the location of the hospital Emergency Operations Plan and/or the Emergency Quick Action Guide

  • Staff can identify the correct actions to take during a Code Gray (Tornado) situation

  • Staff understand their roles and responsibilities during a Code Pink

  • Staff are familiar with the process of accessing a MSDS

  • Medical gas shutoff valves clearly labeled as to which rooms/areas they supply and staff can verbalized who is responsible for shutting them down during an emergency

  • Flashlights are readily available in the department and are functioning/available for emergency situations

Other Issues

  • Please report any additional safety issues, concerns, or comments

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