Audit

TJC Non-Clinical Bee Ready Environment of Care

Observations of environment of care best practice. (Always answer yes)

ENVIRONMENT OF CARE

No items stored under sinks?

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

Equipment has asset tags and is in good repair

No miscellaneous patient care items posy alarms or other 'non-asset' items) found to be damaged or 'on hand' past the acceptable use date

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

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

Hazardous chemicals and flammable agents are labeled and stored properly.

Are multi-use containers/solutions appropriately stored, labeled, and dated

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

Eyewash present and appropriately marked from areas with chemicals requiring 15 minute flush (bleach, dispatch, see labels)

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

Refrigerators: No outdated food/beverages/meds or unapproved items in the refrigerator

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.

Observations for opportunity to improve environment of care best practices

EMERGENCY PREPAREDNESS

Can staff locate medical gas zone shutoff valves.

Staff can verbalize S.A.V.E.

Do staff have access to the FAQ badge card to assist with code recognition

Can staff articulate their role when a disaster plan is paged

Can staff explain their role in fire drills (know location of fire pull stations, fire extinguisher, shutoff valves)

Staff understand Right to Know and MSDS information

INFORMATION MANAGEMENT

Confidential Patient Information:
Cannot be overheard or seen by unauthorized persons:
* Computer terminals signed off when not in use.
* Patient information is not discussed in public areas.
* 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.

LIFE SAFETY

Appropriate storage of boxes and pt care items:
* Not directly on floor (at least 6 inches off of the floor)
* 18" clearance from sprinkler head.
* Boxes stored on shelves close to floor must have solid bottom and high enough to not incur water damage from mopping.

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

Electrical panels are unobstructed and locked

Fire exits and hallways are cleared:
* Egress corridors must have 8ft clearance.
* 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.

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

Fire doors close appropriately/latching/magnetic holds working

Aisles and passages are clear of clutter and obstruction

Slip and trip hazards are absent from the environment

Exit signs are illuminated.

Evacuation route posted & current.

Everyone has ID badges and worn appropriately:
* Staff and Visitors (with pediatric patients)

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

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

Lights and light fixtures are in good repair (no burned out bulbs or damaged fixtures

Crash cart logs are up-to-date

Is critical equipment plugged into red (emergency) outlets

Nurse call lights working.

Wall postings meet applicable fire safety standards

Radiation protection aprons/shields are tagged or identified appropriately

PATIENT SAFETY / NATIONAL PATIENT SAFETY GOALS

Are staff knowledgeable of NPSG's or where to find them
*identify patients correctly
*improve staff communication
*use of medicines safely
*use alarms safely
*prevent infection
*identify patient safety risks
*prevent mistakes in surgery

INFECTION PREVENTION

Are work areas free of staff food, drinks and personal items

Overall appearance of the department clean (top of carts clean, work surfaces clutter free)

High/low dusting completed

Hand Hygiene: empty alcohol gel bottles, empty soap or paper towels, No unapproved lotions

Hand hygiene: do staff demonstrate wash in/wash out

PPE: Readily available, Clearly marked and Worn correctly

Patient food & drinks: No expired items.

Biohazard Waste: Discard in Red Bags with a biohazard symbol, Not overfilled, Covered when transported

Are equipment sterilizing, disinfecting process followed

Are linens stored appropriately(covered/stocking cart covered/clean environment)

Soiled Linen: Properly stored and not overfilled.

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

Sharps Waste: Placed in puncture resistant sharps container, Disposed of when 3/4 full or "full" indicator, Mounted appropriately, and includes expiration date

Air vents: Clean

Curtains, drapes or blinds clean.

Negative and Positive air flow rooms function appropriately.

Ice machines clean.

Water fountains clean and functioning.

MEDICATION MANAGEMENT

Medication rooms are clean and uncluttered and free of dust

Laminar flow hood is used for IV admixture when appropriate.

Area free of distractions.

Medication is appropriately labeled.
* Expiration dates, directions, etc..

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

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

Syringes are labeled when in use.

Medication refrigerator: Only contain medications for current patients.

Medication refrigerator temperature logs are up to date and correction made for out of range

Breast Milk Refrigerators: Only contain milk for current patients.

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

Medication Carts: Doors and drawers are locked.

WAIVED TESTING / POINT OF CARE TESTING

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

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

Additional subjects

Additional comments or issues identified

Work order information

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.