Team Safety Rounds

• Document No.

• Department:

• Conducted on

  Date

• Safety Rounds Team:

• GS01.Are floors & hallways free from trip / fall hazards?

  Yes

  No

  N/A

• GS02. In patient-care areas, are corridors kept clear?

  Yes

  No

  N/A

• GS03. Are wet floor signs being used (as needed)?

  Yes

  No

  N/A

• GS04. Is storage secure to prevent hazards in an earthquake (Furniture/cabinets taller than 5 ft. bolted to wall)?

  Yes

  No

  N/A

• GS05. Is the Emergency Management Reference Guide posted in the area?

  Yes

  No

  N/A

• GS06. Is the Infectious Disease Reference Guide available in patient care areas?

  Yes

  No

  N/A

• GS07. Are all walls in good condition (undamaged, free of holes or water damage)?

  Yes

  No

  N/A

• GS08. Are all ceiling tiles in place and in good condition (unbroken, free of dirt, mold, dust, water stains)?

  Yes

  No

  N/A

• GS09. Are inspection stickers on patient-related electrical equipment current? (check two items)

  Yes

  No

  N/A

• GS10. Is anti-microbial gel available in patient care areas and are containers mounted at least 6” from 120v switches?

  Yes

  No

  N/A

• GS11. Are the areas under the sinks free of patient contact items?

  Yes

  No

  N/A

• GS12. Are wall-mounted sharps containers in appropriate locations and at proper height (52 – 56”)?

  Yes

  No

  N/A

• GS13. Are wall-mounted Sharps Containers less than 3/4 full?

  Yes

  No

  N/A

• GS14. Are the tops of Sharps Containers in patient rooms free of equipment, supplies or other items?

  Yes

  No

  N/A

• GS15. Do all Isolation Rooms have appropriate precaution / isolation signs posted?

  Yes

  No

  N/A

• ED01. Can staff describe how they know if equipment is safe for use?

  Yes

  No

  N/A

• ED02. Can staff explain what to do with faulty or damaged equipment?

  Yes

  No

  N/A

• ED03. Can staff locate the Safety / Emergency policies?

  Yes

  No

  N/A

• ED04. Can staff explain how to report a safety hazard?

  Yes

  No

  N/A

• ED05. Can staff explain what to do if they discover a hazardous material spill or leak?

  Yes

  No

  N/A

• ED06. Can staff define R.A.C.E. and P.A.S.S.?

  Yes

  No

  N/A

• ED07. Can staff locate the nearest fire extinguisher and pull station?

  Yes

  No

  N/A

• ED08. In case of evacuation, does staff know their department’s designated meeting place outside the building?

  Yes

  No

  N/A

Can staff explain their role in any of the following emergencies?

• ED09. Code Pink

  Yes

  No

  N/A

• ED10. Code Purple

  Yes

  No

  N/A

• ED11. Code Green

  Yes

  No

  N/A

• ED 12. Code Gray

  Yes

  No

  N/A

• ED13. Code Silver

  Yes

  No

  N/A

• ED14. Code Orange

  Yes

  No

  N/A

• ED15. Code Yellow

  Yes

  No

  N/A

• ED16. Code Triage

  Yes

  No

  N/A

• ED17. Can staff demonstrate how to look up an SDS?

  Yes

  No

  N/A

• ED18. Who authorizes the shut off of oxygen valves in case of a fire emergency?

  Yes

  No

  N/A

• ED19. Can staff locate airborne isolation rooms and describe how they are monitored when in use?

  Yes

  No

  N/A

• ED20. Can staff describe how to report a workplace injury?

  Yes

  No

  N/A

• ED21. Can staff locate the Hospital Command Center and where the Labor Pool will be established?

  Yes

  No

  N/A

• SM01. Building access is supported (i.e. doors that are to be locked are kept locked and not propped open)?

  Yes

  No

  N/A

• SM02. Are all employees wearing ID badges in plain view?

  Yes

  No

  N/A

• SM03. Are all contractors and vendors wearing I.D. badges in plain view?

  Yes

  No

  N/A

• SM04. Are all valuables (personal items, such as purses, etc.) in a secure place?

  Yes

  No

  N/A

• SM05. Are medication rooms locked when not attended?

  Yes

  No

  N/A

• SM06. Are Nutrition rooms secured as required for the area?

  Yes

  No

  N/A

• HM01. Is personal protective equipment readily available as needed?

  Yes

  No

  N/A

• HM02. Are face masks and other PPE stocked in all patient rooms?

  Yes

  No

  N/A

• HM03. Are spill procedures posted near area of use if hazardous materials are used in the area?

  Yes

  No

  N/A

• HM04. Is there a spill kit available in areas where hazardous chemicals are used (if necessary)?

  Yes

  No

  N/A

• HM05. Are hazardous chemicals stored properly (separating flammables & corrosives, secondary containment, etc.)?

  Yes

  No

  N/A

• HM06. Are all chemical containers In the area properly labeled?

  Yes

  No

  N/A

• HM07. Are biohazard containers labeled on all sides and the lid?

  Yes

  No

  N/A

• HM08. Are the lids on biohazard containers closed?

  Yes

  No

  N/A

• HM09. Do employees segregate the waste properly?

  Yes

  No

  N/A

• Pharmaceutical

• Confidential

• Recyclable

• Chemo

• Bio hazardous

• HM10. Are all gas cylinders stored securely (in racks, on crash carts, gurneys or beds)?

  Yes

  No

  N/A

• HM11. Are O2 cylinder racks labeled “Full” and “Empty” and are cylinders properly separated?

  Yes

  No

  N/A

• HM12. Are there no more than 12 oxygen cylinders (300 ft3) stored in the area?

  Yes

  No

  N/A

• HM13. Are storage areas labeled and locked as required?

  Yes

  No

  N/A

• HM14. Is soiled linen found only in hampers, not on floors?

  Yes

  No

  N/A

• HM15. Are the lids on all soiled linen carts closed?

  Yes

  No

  N/A

• HM16. Are clean linen carts covered or is linen stored in a separate linen closet?

  Yes

  No

  N/A

• HM17. Are eyewash stations and showers available where needed?

  Yes

  No

  N/A

• HM18. Are eye wash stations tested regularly (eyewash stations – weekly, emergency showers - monthly)?

  Yes

  No

  N/A

• HM19. Are housekeeping carts kept locked when unattended?

  Yes

  No

  N/A

• HM20. Are the tops of all housekeeping carts clear of chemicals when unattended?

  Yes

  No

  N/A

• HM21. Are all lead aprons numbered? <br> • Aprons would be found in the following areas:<br> o Radiology<br> o Surgery<br> o Endoscopy<br> o Interventional Services

  Yes

  No

  N/A

• HM22. Are lead aprons in good condition - no visible cracks or flaws?

  Yes

  No

  N/A

• HM23. Are all chemicals used on unit approved (spot check that MSDS’s available for chemicals)?

  Yes

  No

  N/A

• HM24. Do employees maintain a clean medication room?

  Yes

  No

  N/A

• HM25. Are ice machines clean (check drain lines/hoses and inside of dispenser area)?

  Yes

  No

  N/A

• HM26. Are refrigerators appropriately labeled (i.e., “Patient Food Only,” “Staff Food Only”)?

  Yes

  No

  N/A

• HM27. Do patient refrigerators have current temperature logs?

  Yes

  No

  N/A

• HM28. Is all patient food in refrigerator labeled?

  Yes

  No

  N/A

• HM29. Are all refrigerators clean (i.e., Patient Food, Staff Food, Specimen, and medication)?

  Yes

  No

  N/A

• FS01. Are corridors and exits kept clear of debris and equipment?

  Yes

  No

  N/A

• FS02. Are fire exit doors clearly and correctly marked?

  Yes

  No

  N/A

• FS03. Are fire and stairwell doors clear to close? (nothing in the path of the door, not being propped open)

  Yes

  No

  N/A

• FS04. Do fire and stairwell doors latch firmly (and maintain closure)?

  Yes

  No

  N/A

• FS05. Are all combustible materials kept in proper containers and safe, designated locations?

  Yes

  No

  N/A

• FS06. Are fire and hazardous chemical warning signs posted as needed?

  Yes

  No

  N/A

• FS07. In patient care areas, do privacy curtains have 18” clearance from the ceiling - either open or mesh?

  Yes

  No

  N/A

• FS08. Are items stored at least 18” below sprinkler heads?

  Yes

  No

  N/A

• FS09. Are all fire alarm pull stations accessible with 3 foot clearance?

  Yes

  No

  N/A

• FS10. Do all fire extinguishers have 3-foot clearance?

  Yes

  No

  N/A

• FS11. Are fire extinguisher locations clearly marked?

  Yes

  No

  N/A

• FS12. Do fire extinguishers have current inspection tags (monthly checks)?

  Yes

  No

  N/A

• FS13. Are all EXIT signs illuminated?

  Yes

  No

  N/A

• UM01. Are all outlets / electrical box cover plates in good shape, not damaged or missing?

  Yes

  No

  N/A

• UM02. Are emergency power outlets being used for critical equipment only?

  Yes

  No

  N/A

• UM03. Are all electrical panels accessible – not blocked by carts, boxes, trash cans, or other items?

  Yes

  No

  N/A

• UM04. Are all breakers labeled? (If accessible)

  Yes

  No

  N/A

• UM05. Are all electrical panels kept locked?

  Yes

  No

  N/A

• UM06. Are Medical Gas Zone Valves marked with identity and locations served?

  Yes

  No

  N/A

• UM07. Are Medical Gas Zone Valves accessible for immediate access?

  Yes

  No

  N/A

• UM08. Are negative pressure rooms tested monthly?

  Yes

  No

  N/A

• UM09. Are there permanently mounted outlet strips?

  Yes

  No

  N/A

• UM10. Are mechanical and electrical rooms kept locked?

  Yes

  No

  N/A