Information
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Audit Title
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Document No.
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
TJC Non-Clinical Bee Ready Environment of Care
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Observations of environment of care best practice. (Always answer yes)
ENVIRONMENT OF CARE
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No items stored under sinks?
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Equipment / Furniture:<br> * No broken equipment or furniture stored on the patient care units.<br> * Coverings are intact - no rips or repairs needed.
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Equipment has asset tags and is in good repair
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No miscellaneous patient care items posy alarms or other 'non-asset' items) found to be damaged or 'on hand' past the acceptable use date
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Potential safety hazards: Housekeeping & Maintenance carts & buckets are attended or locked. All fluids are labeled.
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Hazardous rooms are locked: EVS closets, supply closets, mechanical rooms and electrical panels.
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Hazardous chemicals and flammable agents are labeled and stored properly.
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Are multi-use containers/solutions appropriately stored, labeled, and dated
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Eyewash stations: Inspection tags are present and up to date.
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Eyewash present and appropriately marked from areas with chemicals requiring 15 minute flush (bleach, dispatch, see labels)
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Refrigerators: Contain only those items designed for that refrigerator (specimen, medications or patient food)
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Refrigerators: No outdated food/beverages/meds or unapproved items in the refrigerator
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Refrigerators: If manually monitored, logs are complete. Both manual and temp track-documentation is present for actions taken to correct out of range temps.
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Blanket, item warmers: Set to maintain temp of 130. Necessary logs completed including actions taken to out of range temperature readings.
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Electrical safety: Use of hospital grade power strips, plugs & receptacles in good condition.
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No outer shipping carton boxes in patient care areas.
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Observations for opportunity to improve environment of care best practices
EMERGENCY PREPAREDNESS
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Can staff locate medical gas zone shutoff valves.
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Staff can verbalize S.A.V.E.
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Do staff have access to the FAQ badge card to assist with code recognition
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Can staff articulate their role when a disaster plan is paged
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Can staff explain their role in fire drills (know location of fire pull stations, fire extinguisher, shutoff valves)
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Staff understand Right to Know and MSDS information
INFORMATION MANAGEMENT
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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.
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No clipboards displayed as sign-in sheets when multiple patient names on the list.
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If fax machine is in public area, patient information is quickly removed.
LIFE SAFETY
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Appropriate storage of boxes and pt care items:<br> * Not directly on floor (at least 6 inches off of the 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.
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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.
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Electrical panels are unobstructed and locked
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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.
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Fire alarm pull stations, fire extinguishers, medical gas shutoff valves are not blocked.
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Fire extinguishers have been inspected monthly.
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Fire doors are not blocked or propped and when closed there is positive latching.
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Fire doors close appropriately/latching/magnetic holds working
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Aisles and passages are clear of clutter and obstruction
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Slip and trip hazards are absent from the environment
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Exit signs are illuminated.
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Evacuation route posted & current.
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Everyone has ID badges and worn appropriately:<br> * Staff and Visitors (with pediatric patients)
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Ceiling tiles are in place, no cracks, holes, misaligned or visible stains.
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Floors, ceilings, walls, and other surfaces intact and free from holes.
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Lights and light fixtures are in good repair (no burned out bulbs or damaged fixtures
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Crash cart logs are up-to-date
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Is critical equipment plugged into red (emergency) outlets
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Nurse call lights working.
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Wall postings meet applicable fire safety standards
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Radiation protection aprons/shields are tagged or identified appropriately
PATIENT SAFETY / NATIONAL PATIENT SAFETY GOALS
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Are staff knowledgeable of NPSG's or where to find them<br>*identify patients correctly<br>*improve staff communication<br>*use of medicines safely<br>*use alarms safely<br>*prevent infection<br>*identify patient safety risks<br>*prevent mistakes in surgery
INFECTION PREVENTION
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Are work areas free of staff food, drinks and personal items
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Overall appearance of the department clean (top of carts clean, work surfaces clutter free)
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High/low dusting completed
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Hand Hygiene: empty alcohol gel bottles, empty soap or paper towels, No unapproved lotions
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Hand hygiene: do staff demonstrate wash in/wash out
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PPE: Readily available, Clearly marked and Worn correctly<br>
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Patient food & drinks: No expired items.
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Biohazard Waste: Discard in Red Bags with a biohazard symbol, Not overfilled, Covered when transported<br>
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Are equipment sterilizing, disinfecting process followed
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Are linens stored appropriately(covered/stocking cart covered/clean environment)
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Soiled Linen: Properly stored and not overfilled.
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Separation of clean vs. dirty supplies & equipment:<br> * Clearly marked<br> * Clean items if stored in soiled utility are covered & clearly marked
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Sharps Waste: Placed in puncture resistant sharps container, Disposed of when 3/4 full or "full" indicator, Mounted appropriately, and includes expiration date
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Air vents: Clean
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Curtains, drapes or blinds clean.
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Negative and Positive air flow rooms function appropriately.
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Ice machines clean.
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Water fountains clean and functioning.
MEDICATION MANAGEMENT
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Medication rooms are clean and uncluttered and free of dust
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Laminar flow hood is used for IV admixture when appropriate.
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Area free of distractions.
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Medication is appropriately labeled.<br> * Expiration dates, directions, etc..
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All medications, needles and syringes are secured in locked cabinet or locked room or under constant surveillance.
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Medications stored appropriately to maintain stability.
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Medications, formula, & solutions not expired beyond expiration date.
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Opened multi-dose vials dated and initialed. Not expired.
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Code Carts:<br> * Locked and marked with then first drug to expire.<br> * Checked per policy.<br> * Include defibrillator check.<br> * 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
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Syringes are labeled when in use.
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Medication refrigerator: Only contain medications for current patients.
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Medication refrigerator temperature logs are up to date and correction made for out of range
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Breast Milk Refrigerators: Only contain milk for current patients.
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Patient Bedside: <br> *. IV tubing is labeled per policy.<br> *. Medication is secured and labeled.<br> *. All solutions are labeled at the bedside.
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Medication Carts: Doors and drawers are locked.
WAIVED TESTING / POINT OF CARE TESTING
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Point of Care testing lab controls documented and control solution labeled & dated.<br> *. Reagents, i Stat analyzes, glucometers, GEMS
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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>
Additional subjects
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Additional comments or issues identified
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Work order information
