A. PREVIOUS AUDITS

  • Has the last audit been reviewed?

  • Have all outstanding concerns been addressed?

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  • Identify outstanding concerns.

B. TOP REPEAT ITEMS

  • Hallways clear of clutter.

  • Exit doors unobstructed.

  • Are doors secured after hours?

  • Storage (boxes etc.) are stored no less than 18" from sprinkler head.

  • Storages (boxes etc.) are 6" above floor.

  • No cracked, stained, or missing ceiling tiles.

  • Appropriate hazard signs posted on the doorway?

  • No damaged building materials (e.g. walls, floors, ceilings, furniture, furnishings)

C. STAFF AWARENESS

  • Staff can identify Emergency Response Resources.
    Safety info on ID
    TJUH Intranet
    Emergency Response Card

  • Staff are wearing ID cards.

  • Employees know how to access SDSs, Chemical Inventory List available.

  • Personal items kept secured in work areas. (Handbags, Wallets)

  • Employees know the process for reporting a security incident, chemical spill, Code Red.
    Dial 811/TJUH Dial 77/MHD

  • Are sharp containers filled below the indicator line or 3/4 capacity?

  • Staff demonstrates knowledge of Code D/Disaster response.

  • Personal Protective Equipment (PPE) available and worn properly? (Fastened lab coat, no alterations to coat, gloves worn when working with specimens)

D. Emergency Preparedness

  • Electrical closet/panels, mechanical closets, housekeeping closets are locked.

  • Are spill kits present and stocked with appropriate supplies?

  • Fire extinguishers are clearly marked (signage).

  • Fire extinguishers have been tested within the last year?

  • Fire extinguishers unobstructed.

  • Exits illuminated; clearly and correctly marked.

  • Pull stations unobstructed (3' clear) and intact.

  • Smoke/Fire Doors close freely.

  • No smoking policy enforced (no visible signs of non-compliance).

  • Fire Tower Exits unlocked from floor (unless approved variance - special conditions).

  • Proper stair identification signage at landings.

  • Fire evacuation diagram signage posted at elevator call stations/landings.

  • Access control devices (card readers, combination locks) are in use and working properly.

  • Area is adequately lighted.

  • Sprinkler heads are free of foreign materials.

  • No unauthorized appliances (space heater, toaster).

  • Extension cords are not substituted for permanent wiring. Power strip should not be plugged into power strips (only approved surge power strips)

  • Gas cylinders properly secured.
    Gas storage area has a labeled door stating "Caution oxidizing gases stored within. No smoking"

  • Does a laboratory have an eyewash and if so is the I wash within 10 seconds travel time or 55 feet of the area where hazardous chemicals are used?

  • Eye wash maintenance is up to date?

E. Chemical safety

  • Chemicals stored properly.

  • Are hazardous liquids stored in below eye level?

  • Are chemicals labeled properly, for example no abbreviations, hazard, dates? (Check secondary containers)

  • Are potentially hazardous chemicals disposed of properly?

  • Are waste bottles properly labeled? Are they closed when not in use?

F. Laboratory Equipment

  • Equipment is clean and free from damage.

  • Equipment is free of frayed wires and/or faulty plugs.

G. Fume Hoods

  • Are all fume hoods unobstructed (i.e. No equipment and bottles the path of the exhaust)?

  • Have all the fume hoods been tested within the last year?

H. MISCELLANOUS

  • Alcohol based hand washing solution readily available (staff handwashing).

  • No food or drink in clinical work area.

  • Refrigerator temperature log completed and up to date.

  • Standards of cleanliness are maintained throughout.

  • HVAC vents free of dust.

I. ADDITIONAL FINDINGS

  • Is there any additional findings?

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  • Additionally findings 1:

  • Is there any additional findings?

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  • Additionally findings 2:

  • Is there any additional findings?

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  • Additionally findings 3:

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