General Safety Section
GS01.Are floors & hallways free from trip / fall hazards?
GS02. In patient-care areas, are corridors kept clear?
GS03. Are wet floor signs being used (as needed)?
GS04. Is storage secure to prevent hazards in an earthquake (Furniture/cabinets taller than 5 ft. bolted to wall)?
GS05. Is the Emergency Management Reference Guide posted in the area?
GS06. Is the Infectious Disease Reference Guide available in patient care areas?
GS07. Are all walls in good condition (undamaged, free of holes or water damage)?
GS08. Are all ceiling tiles in place and in good condition (unbroken, free of dirt, mold, dust, water stains)?
GS09. Are inspection stickers on patient-related electrical equipment current? (check two items)
GS10. Is anti-microbial gel available in patient care areas and are containers mounted at least 6” from 120v switches?
GS11. Are the areas under the sinks free of patient contact items?
GS12. Are wall-mounted sharps containers in appropriate locations and at proper height (52 – 56”)?
GS13. Are wall-mounted Sharps Containers less than 3/4 full?
GS14. Are the tops of Sharps Containers in patient rooms free of equipment, supplies or other items?
GS15. Do all Isolation Rooms have appropriate precaution / isolation signs posted?
General Safety Interview
ED01. Can staff describe how they know if equipment is safe for use?
ED02. Can staff explain what to do with faulty or damaged equipment?
ED03. Can staff locate the Safety / Emergency policies?
ED04. Can staff explain how to report a safety hazard?
ED05. Can staff explain what to do if they discover a hazardous material spill or leak?
ED06. Can staff define R.A.C.E. and P.A.S.S.?
ED07. Can staff locate the nearest fire extinguisher and pull station?
ED08. In case of evacuation, does staff know their department’s designated meeting place outside the building?
ED09. Code Pink
ED10. Code Purple
ED11. Code Green
ED 12. Code Gray
ED13. Code Silver
ED14. Code Orange
ED15. Code Yellow
ED16. Code Triage
ED17. Can staff demonstrate how to look up an SDS?
ED18. Who authorizes the shut off of oxygen valves in case of a fire emergency?
ED19. Can staff locate airborne isolation rooms and describe how they are monitored when in use?
ED20. Can staff describe how to report a workplace injury?
ED21. Can staff locate the Hospital Command Center and where the Labor Pool will be established?
SM01. Building access is supported (i.e. doors that are to be locked are kept locked and not propped open)?
SM02. Are all employees wearing ID badges in plain view?
SM03. Are all contractors and vendors wearing I.D. badges in plain view?
SM04. Are all valuables (personal items, such as purses, etc.) in a secure place?
SM05. Are medication rooms locked when not attended?
SM06. Are Nutrition rooms secured as required for the area?
Hazardous Materials & Waste Managment
HM01. Is personal protective equipment readily available as needed?
HM02. Are face masks and other PPE stocked in all patient rooms?
HM03. Are spill procedures posted near area of use if hazardous materials are used in the area?
HM04. Is there a spill kit available in areas where hazardous chemicals are used (if necessary)?
HM05. Are hazardous chemicals stored properly (separating flammables & corrosives, secondary containment, etc.)?
HM06. Are all chemical containers In the area properly labeled?
HM07. Are biohazard containers labeled on all sides and the lid?
HM08. Are the lids on biohazard containers closed?
HM09. Do employees segregate the waste properly?
HM10. Are all gas cylinders stored securely (in racks, on crash carts, gurneys or beds)?
HM11. Are O2 cylinder racks labeled “Full” and “Empty” and are cylinders properly separated?
HM12. Are there no more than 12 oxygen cylinders (300 ft3) stored in the area?
HM13. Are storage areas labeled and locked as required?
HM14. Is soiled linen found only in hampers, not on floors?
HM15. Are the lids on all soiled linen carts closed?
HM16. Are clean linen carts covered or is linen stored in a separate linen closet?
HM17. Are eyewash stations and showers available where needed?
HM18. Are eye wash stations tested regularly (eyewash stations – weekly, emergency showers - monthly)?
HM19. Are housekeeping carts kept locked when unattended?
HM20. Are the tops of all housekeeping carts clear of chemicals when unattended?
HM21. Are all lead aprons numbered?
• Aprons would be found in the following areas:
o Interventional Services
HM22. Are lead aprons in good condition - no visible cracks or flaws?
HM23. Are all chemicals used on unit approved (spot check that MSDS’s available for chemicals)?
HM24. Do employees maintain a clean medication room?
HM25. Are ice machines clean (check drain lines/hoses and inside of dispenser area)?
HM26. Are refrigerators appropriately labeled (i.e., “Patient Food Only,” “Staff Food Only”)?
HM27. Do patient refrigerators have current temperature logs?
HM28. Is all patient food in refrigerator labeled?
HM29. Are all refrigerators clean (i.e., Patient Food, Staff Food, Specimen, and medication)?
Fire Safety Management
FS01. Are corridors and exits kept clear of debris and equipment?
FS02. Are fire exit doors clearly and correctly marked?
FS03. Are fire and stairwell doors clear to close? (nothing in the path of the door, not being propped open)
FS04. Do fire and stairwell doors latch firmly (and maintain closure)?
FS05. Are all combustible materials kept in proper containers and safe, designated locations?
FS06. Are fire and hazardous chemical warning signs posted as needed?
FS07. In patient care areas, do privacy curtains have 18” clearance from the ceiling - either open or mesh?
FS08. Are items stored at least 18” below sprinkler heads?
FS09. Are all fire alarm pull stations accessible with 3 foot clearance?
FS10. Do all fire extinguishers have 3-foot clearance?
FS11. Are fire extinguisher locations clearly marked?
FS12. Do fire extinguishers have current inspection tags (monthly checks)?
FS13. Are all EXIT signs illuminated?
UM01. Are all outlets / electrical box cover plates in good shape, not damaged or missing?
UM02. Are emergency power outlets being used for critical equipment only?
UM03. Are all electrical panels accessible – not blocked by carts, boxes, trash cans, or other items?
UM04. Are all breakers labeled? (If accessible)
UM05. Are all electrical panels kept locked?
UM06. Are Medical Gas Zone Valves marked with identity and locations served?
UM07. Are Medical Gas Zone Valves accessible for immediate access?
UM08. Are negative pressure rooms tested monthly?
UM09. Are there permanently mounted outlet strips?
UM10. Are mechanical and electrical rooms kept locked?