Thomas Jefferson Clinical Laboratories Safety Inspection

• Document No.

• Conducted on

  Date

• Department (Select one)

  Select Blood Bank Donor Center Microbiology Center City Chemistry Center City Hematology Immunology Flow Cytometry Electron Microscopy Molecular Pathology Central Receiving Jefferson Infusion Center JHN MHD Navy Yard Surgical Pathology Cytopathology Phleb (833 Chestnut) Phleb (Main) Phleb (Infusion) Phleb (Pavilion) Computer Services (Informatics)

  • Blood Bank
  • Donor Center
  • Microbiology
  • Center City Chemistry
  • Center City Hematology
  • Immunology
  • Flow Cytometry
  • Electron Microscopy
  • Molecular Pathology
  • Central Receiving
  • Jefferson Infusion Center
  • JHN
  • MHD
  • Navy Yard
  • Surgical Pathology
  • Cytopathology
  • Phleb (833 Chestnut)
  • Phleb (Main)
  • Phleb (Infusion)
  • Phleb (Pavilion)
  • Computer Services (Informatics)

• Prepared by

  Select Alex Vuong Raquel Dennis Lisa Hall Liam Nisenfeld Molly Kelly Lisa Morano Celena King David Peterson Angel Borishek-Quaile Peggy Rapa Kathy Schroeder Irma Silva Thomas Speakman Micheline Thera Vicky Ward Aryana Treweek Nandita Patel

  • Alex Vuong
  • Raquel Dennis
  • Lisa Hall
  • Liam Nisenfeld
  • Molly Kelly
  • Lisa Morano
  • Celena King
  • David Peterson
  • Angel Borishek-Quaile
  • Peggy Rapa
  • Kathy Schroeder
  • Irma Silva
  • Thomas Speakman
  • Micheline Thera
  • Vicky Ward
  • Aryana Treweek
  • Nandita Patel

Previous Audits

• Has the last audit been reviewed?

  Yes

  No

  N/A

• Have all outstanding concerns been addressed?

  Yes

  No

  N/A

Quality Management

• The laboratory has a procedure for employees and patients to communicate concerns about quality and safety.

  Yes

  No

  N/A

• If any complaints have been noted, is there proper follow up?

  Yes

  No

  N/A

• The official CAP sign is posted within the laboratory?

  Yes

  No

  N/A

• If there are specimen collectors or phlebotomists in the department you are inspecting, have those individuals been trained on proper collection and is there supporting documentation for this training? (Select N/A if not applicable)<br>

  Yes

  No

  N/A

• If the lab allows for mislabeled specimens to be relabeled, is there documentation of this change that includes a signature of the person relabeling the specimen?

  Yes

  No

  N/A

• All persons who package and ships infectious agents are trained.

  Yes

  No

  N/A

• If your area stores specimen collection devices (blood collection tubes, transport media, culture swabs) are not expired and stored per manufacturer recommendations. (Note: check to see if there are temp. requirements. If there are temp. requirements, is the temp monitored?)

  Yes

  No

  N/A

• Do all specimen requisitions have the following elements:<br>Patient Identification<br>Patient Sex<br>Patient's DOB<br>Name and address of the physician ordering the test (OUTPATIENT ONLY)<br>Test(s) requested<br>Last menstrual period (for gyn specimens ONLY)<br>Time and date of specimen collection (can be on the container)<br>

  Yes

  No

  N/A

• All centrifuges have been checked within the last year.

  Yes

  No

  N/A

• Thermometers used in the refrigerators and/or freezers have been verified and checked in the last year.

  Yes

  No

  N/A

• The thermometers are not expired. (Some digital thermometers have an expiration date, please check all thermometers within your section)

  Yes

  No

  N/A

• Glassware used in the laboratory is cleaned appropriately and methods to ensure complete removal of detergents (if this is applicable to the lab there must be documentation of the cleaning)

  Yes

  No

  N/A

• If yes above, is there a log.

  no

  yes

Enviroment

• If instruments, reagents stored outside a refrigerator or freezer, and/or collection devices require a specified temp/humid range, the temperature and/or humidity is checked and documented daily.

  Yes

  No

  N/A

• Is the temp and humidity of the room within acceptable limits? (see above log)

  Yes

  No

  N/A

• Are all lights in working order?

  Yes

  No

  N/A

• Are all ceiling tiles undamaged? (No water marks, damaged, or missing tiles)<br>

  Yes

  No

  N/A

• Exposure to bright sunlight is minimized

  Yes

  No

  N/A

Safety

• There is a comprehensive evacuation plan for the laboratory that includes accommodations for disabled persons.

  Yes

  No

  N/A

• All employees in the laboratory know where to locate the SDS. (Ask up to 3 employees, correct answers include online and books located within your lab)<br>

  Yes

  No

  N/A

• All fire extinguishers have been inspected and are up to date (check the tag on the extinguishers)

  Yes

  No

  N/A

• All UV light sources have warning signs posted near the source.

  Yes

  No

  N/A

• Chemical waste is disposed of properly per policy

  Yes

  No

  N/A

• All sharps containers are below the required fill line

  Yes

  No

  N/A

• All employees are wearing their lab coats while in the laboratory at the time of the inspection.

  Yes

  No

  N/A

• All employees are wearing gloves while handling patient specimens at the time of the inspection.

  Yes

  No

  N/A

• All fire alarm stations are visible and unobstructed.

  Yes

  No

  N/A

• Heaters/fans in use? If so, are they approved by the QA Coordinator?

  Yes but approved

  Yes not approved

  Yes unsure if approved

  No

• Waste containers properly labeled.

  Yes

  No

  N/A

• All flammable gas cylinders are secured.

  Yes

  No

  N/A

• Eyewash maintenance up to date?

  Yes

  No

  N/A

• Spill kits available and checked within the last year for effectiveness.

  Yes

  No

  N/A

• All hoods tested within the year.

  Yes

  No

  N/A

• Personal items are secured.

  Yes

  No

  N/A

• Employees know the process for reporting a security incident, chemical spill, Code red? (Ask 2 employees) Dial 811 or 77 (MHD campus)

  Yes

  No

  N/A

• Sharps containers filled below the indicator line or 3/4 capacity.

  Yes

  No

  N/A

Accreditation items

• All staff know the location of the collection manual online. (ask a few staff members)

  Yes

  No

  N/A

• All reagents are labeled appropriately. (an open date and expiration date should be on every container that is opened)

  Yes

  No

  N/A

• All reagents are not expired. (If an expiration date is not indicated by the manufacturer the lab must assign one based on stability of the product)

  Yes

  No

  N/A

• All secondary containers are properly labeled (secondary containers are defined as any container where a chemical and/or reagent is poured into from the manufacturer's container) (Proper labeling includes but is not limited to full name of the chemical/reagent, a warning label and the date of transfer)

  Yes

  No

  N/A

• The floors are clean.

  Yes

  No

  N/A

• Storage (boxes etc.) and equipment are no less that 18" from the bottom of a sprinkle head

  Yes

  No

  N/A

• Storage (boxes etc.) are 6" above the floor

  Yes

  No

  N/A

• Additional findings?

  Yes

  No

  N/A

• Add signature

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