Smile Brands Annual Safety Audit - Field Leaders

• Site conducted

  Select

• Conducted on

  Date

• Safety OSHA Coordinator

• Market/DMO/RD

Sterilization

• Overgarment, mask, eye protection and utility gloves are worn when handling contaminated instruments

  Yes

  No

  N/A

• Date Compliance Achieved with Initials

• Ultrasonic solution is changed daily or more frequently if needed

  Yes

  No

  N/A

• Date Compliance Achieved with Initials

• Instrument basket or tongs are used to removed instruments from the ultrasonic cleaner

  Yes

  No

  N/A

• Date Compliance Achieved with Initials

• Spore testing is being done weekly and recorded in log

  Yes

  No

  N/A

• Date Compliance Achieved with Initials

• Class V integrators are available

  Yes

  No

  N/A

• Date Compliance Achieved with Initials

• All sterilization packs removed from the sterilizer are inspected for indicator color change and to ensure no punctures.

  Yes

  No

  N/A

• Date Compliance Achieved with Initials

• Sterilization pouches are marked with date and sterilizer #

  Yes

  No

  N/A

• Date Compliance Achieved with Initials

• Chemical containers are covered

  Yes

  No

  N/A

• Date Compliance Achieved with Initials

Operatories

• Are barriers being used on hard to disinfect surfaces (light handles, x-ray heads, etc.)

  Yes

  No

  N/A

• Date Compliance Achieved with Initials

• Needle recapping device is available & being used

  Yes

  No

  N/A

• Date Compliance Achieved with Initials

• Reusable Contaminated sharps are transported in a leak-proof, puncture resistant container

  Yes

  No

  N/A

• Date Compliance Achieved with Initials

• Secondary container labels are in place and legible

  Yes

  No

  N/A

• Date Compliance Achieved with Initials

• Chairside traps are changed weekly

  Yes

  No

  N/A

• Date Compliance Achieved with Initials

• Work areas are free from tripping and falling hazards

  Yes

  No

  N/A

• Date Compliance Achieved with Initials

• Food, beverages and make-up are not allowed in clinical areas

  Yes

  No

  N/A

• Date Compliance Achieved with Initials

PPE

• Appropriate PPE’s are in use with patient care

  Yes

  No

  N/A

• Date Compliance Achieved with Initials

• Overgarments are worn only in clinical areas

  Yes

  No

  N/A

• Date Compliance Achieved with Initials

• Scrubs/over-garments are removed if contaminated

  Yes

  No

  N/A

• Date Compliance Achieved with Initials

• Long sleeve garments are worn when there is potential for splash/splatter

  Yes

  No

  N/A

• Date Compliance Achieved with Initials

• There are no evident areas of cross-contamination

  Yes

  No

  N/A

• Date Compliance Achieved with Initials

• Hand hygiene is occurring before and after treating patients and wearing gloves

  Yes

  No

  N/A

• Date Compliance Achieved with Initials

• Contaminated gloves are not to be worn when writing in charts

  Yes

  No

  N/A

• Date Compliance Achieved with Initials

• Keyboards and computer mouse are barrier protected

  Yes

  No

  N/A

• Date Compliance Achieved with Initials

Waste Disposal

• Are the sharps container(s) available at point of use and replaced when contents reach the full line

  Yes

  No

  N/A

• Contaminated disposable sharps are not to be transported for central disposal.

• Date Compliance Achieved with Initials

• Contaminated disposable sharps are not to be transported for central disposal.

• Regulated waste is covered

  Yes

  No

  N/A

• Date Compliance Achieved with Initials

• Non-regulated waste disposal is adequate

  Yes

  No

  N/A

• Date Compliance Achieved with Initials

Waterline Maintenance

• Are dental unit waterlines flushed for 2 minutes at the beginning of the day and 30 seconds between patients

  Yes

  No

  N/A

• Date Compliance Achieved with Initials

• Is a waterline maintenance product being used

  Yes

  No

  N/A

• Date Compliance Achieved with Initials

• Are maintenance logs for dental unit waterlines present

  Yes

  No

  N/A

• Date Compliance Achieved with Initials

• Is testing of waterlines completed every 3 months

  Yes

  No

  N/A

• Date Compliance Achieved with Initials

• Is the OSHA/Safety Officer aware of the steps to follow for a failed waterline test

  Yes

  No

  N/A

Emergency Medical Equipment and Medical Gases

• The Spill Kit is complete

  Yes

  No

  N/A

• Date Compliance Achieved with Initials

• All staff are informed of the location of the Spill Kit

  Yes

  No

  N/A

• Date Compliance Achieved with Initials

• First aid supplies complete

  Yes

  No

  N/A

• Date Compliance Achieved with Initials

• AED adult and pediatric pads are not expired, AED unit is in working order, and AED monthly inspection has been completed according to company policy and documented on www.track-pro.com? (Track-Pro for Smile Brands only)

  Yes

  No

  N/A

• Date Compliance Achieved with Initials

• Eyewash station(s) are in place, not connected to hot water, correctly capped, labeled, and are flushed weekly

  Yes

  No

  N/A

• Date Compliance Achieved with Initials

• Oxygen and/or nitrous tanks are secured

  Yes

  No

  N/A

• Date Compliance Achieved with Initials

• Are all medical gas gauges in place and working properly

  Yes

  No

  N/A

• Date Compliance Achieved with Initials

• The door for the Medical Gas closet labeled appropriately

  Yes

  No

  N/A

• Date Compliance Achieved with Initials

• All door locks for exterior medical gas storage is in place & working correctly

  Yes

  No

  N/A

• Date Compliance Achieved with Initials

• Emergency Oxygen Tank is secured and full

  Yes

  No

  N/A

• Date Compliance Achieved with Initials

• Emergency Medical Kit is complete and there are no expired drugs

  Yes

  No

  N/A

• Date Compliance Achieved with Initials

Radiation

Radiation Section

• Are shielding/lead aprons free of cracks, tears, etc

  Yes

  No

  N/A

• Order replacement

• Are any x-ray units due for calibration/equipment performance evaluation within the next 2 months

  Yes

  No

  N/A

• Schedule a Technician (Smile Brands) or place an equipment support ticket (Midwest)

• X-ray registration current

  Yes

  No

  N/A

Analog Imaging

• Is there analog imaging

  Yes

  No

  N/A

• Description of analog usage

• Developer and fixer changed and logs present

  Yes

  No

  N/A

• Is there a chemical label present on the processor

  Yes

  No

  N/A

• Temperature for developer documented and logs present

  Yes

  No

  N/A

• Dark room leak test logs present

  Yes

  No

  N/A

• Darkroom requirements log present

  Yes

  No

  N/A

• Crabtree/stepwedge log present

  Yes

  No

  N/A

• Lead Foil Recycling bucket present

  Yes

  No

  N/A

• Are the film holders/aiming devices bagged and stored properly

  Yes

  No

  N/A

Digital Imaging

• Is there digital imaging for intraoral xrays

  Yes

  No

  N/A

Sensor

• Does the office use sensors?

  Yes

  No

  N/A

• Are sensors hanging properly to avoid kinks in the cable

  Yes

  No

  N/A

• Are sensors disinfected properly

  Yes

  No

  N/A

• Are barriers used on sensors

  Yes

  No

  N/A

Phosphor Plates

• Does the office use phosphor plates

  Yes

  No

  N/A

• Are barriers being used on phosphor plates

  Yes

  No

  N/A

• Are the film holders/aiming devices bagged and stored properly

  Yes

  No

  N/A

Laboratory

• Lab handpiece is sterilized/disinfected after each case

  Yes

  No

  N/A

• Date Compliance Achieved with Initials

• Rag wheels and burs are sterilized after each case

  Yes

  No

  N/A

• Date Compliance Achieved with Initials

• New pumice is used for every case

  Yes

  No

  N/A

• Date Compliance Achieved with Initials

• Impressions are disinfected before being poured up or sent out

  Yes

  No

  N/A

• Date Compliance Achieved with Initials

• Are all models labeled and stored properly

  Yes

  No

  N/A

• Date Compliance Achieved with Initials

• Are the Lab plaster traps well sealed and changed out appropriately

  Yes

  No

  N/A

• Date Compliance Achieved with Initials

• Is the Lab floor clear of extra plaster, storage items, etc

  Yes

  No

  N/A

• Date Compliance Achieved with Initials

Mechanical Room

• Amalgam separator present, inspected weekly and logged

  Yes

  No

  N/A

• Date Compliance Achieved with Initials

• Is the mechanical room free of clutter, trash and storage items

  Yes

  No

  N/A

• Date Compliance Achieved with Initials

• Is the mechanical room free of ANY water leaks

  Yes

  No

  N/A

• Date Compliance Achieved with Initials

• Is the mechanical room well ventilated to the outside air

  Yes

  No

  N/A

• Date Compliance Achieved with Initials

• Is the mechanical room free of unusual smells or excessive temperature

  Yes

  No

  N/A

• Date Compliance Achieved with Initials

• Is the mechanical room free of unusual sounds from the equipment

  Yes

  No

  N/A

• Date Compliance Achieved with Initials

Hazardous Chemicals

• There is an SDS readily available for each hazardous substance used

  Yes

  No

  N/A

• Date Compliance Achieved with Initials

• There is a current list of hazardous substances used in the workplace

  Yes

  No

  N/A

• Date Compliance Achieved with Initials

Accessibility and Safety

• Aisles and passageways are kept clear

  Yes

  No

  N/A

• Date Compliance Achieved with Initials

• There is safe clearance for walking in aisles where motorized or mechanical handling equipment is operating (i.e., wheelchairs)

  Yes

  No

  N/A

• Date Compliance Achieved with Initials

• Changes of elevation/direction readily identifiable

  Yes

  No

  N/A

• Date Compliance Achieved with Initials

• There is adequate headroom for the entire length of any isle or walkway

  Yes

  No

  N/A

• Date Compliance Achieved with Initials

• Stair rails or handrails are on all stairways having four or more risers

  Yes

  No

  N/A

• Date Compliance Achieved with Initials

• Wet surfaces covered with non-slip materials and spilled materials are cleaned up immediately

  Yes

  No

  N/A

• Date Compliance Achieved with Initials

• Exits are accessible without obstruction

  Yes

  No

  N/A

• Date Compliance Achieved with Initials

• Illuminated exit signs are in working order (If applicable)

  Yes

  No

  N/A

• Date Compliance Achieved with Initials

• Evacuation routes posted as required

  Yes

  No

  N/A

• Date Compliance Achieved with Initials

• Lights are in working order

  Yes

  No

  N/A

• Date Compliance Achieved with Initials

• Electrical panel/fuse box is not blocked

  Yes

  No

  N/A

• Date Compliance Achieved with Initials

• Flexible cords and cables are free of splices or tape

  Yes

  No

  N/A

• Date Compliance Achieved with Initials

• Extension cords have a grounding conductor

  Yes

  No

  N/A

• Date Compliance Achieved with Initials

• All defective equipment is repaired or replaced promptly

  Yes

  No

  N/A

• Date Compliance Achieved with Initials

• The fire extinguisher(s) is mounted and locator signs are in place (If applicable)

  Yes

  No

  N/A

• Date Compliance Achieved with Initials

• All fire extinguishers have been inspected. The needle indicator is in the “charged” position or green zone

  Yes

  No

  N/A

• Date Compliance Achieved with Initials

• Restrooms are clean and sanitary

  Yes

  No

  N/A

• Date Compliance Achieved with Initials

Documentation

• State specific posters are in place

  Yes

  No

  N/A

• Date Compliance Achieved with Initials

• Written manuals are organized

  Yes

  No

  N/A

• Date Compliance Achieved with Initials

• Written manuals are complete

  Yes

  No

  N/A

• Date Compliance Achieved with Initials

• All training records are maintained

  Yes

  No

  N/A

• Date Compliance Achieved with Initials

• Has there been a transition in the Safety Officer position

  Yes

  No

  N/A

• Has the new Safety Officer completed training

  Yes

  No

  N/A

• Safety Committee meeting minutes are current

  Yes

  No

  N/A

• Date Compliance Achieved with Initials

• Date of last Safety Meeting

• Corrective Actions/ Comments