Thomas Jefferson University Hospital Clinical Laboratory Internal Safety Inspection 2014

• Organization

  TJUH - CENTER CITY

  TJUH - JHN

  Ambulatory Site

  TJUH - Methodist

• Building/Floor

• Site

• Manager/Supervisor

• Conducted on

  Date

• Prepared by

• Staff on tour:

  Select Charles Payne James Kerrigan Elio Boffa Dennis Rudloff Mary Ehly Michael Curry

  • Charles Payne
  • James Kerrigan
  • Elio Boffa
  • Dennis Rudloff
  • Mary Ehly
  • Michael Curry

A. PREVIOUS AUDITS

• Has the last audit been reviewed?

  Yes

  No

  N/A

• Have all outstanding concerns been addressed?

  Yes

  No

  N/A
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• Identify outstanding concerns.

B. TOP REPEAT ITEMS

• Hallways clear of clutter.

  Yes

  No

  N/A

• Exit doors unobstructed.

  Yes

  No

  N/A

• Are doors secured after hours?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• No cracked, stained, or missing ceiling tiles.

  Yes

  No

  N/A

• Appropriate hazard signs posted on the doorway?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

C. STAFF AWARENESS

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

  Yes

  No

  N/A

• Staff are wearing ID cards.

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Staff demonstrates knowledge of Code D/Disaster response.

  Yes

  No

  N/A

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

  Yes

  No

  N/A

D. Emergency Preparedness

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

  Yes

  No

  N/A

• Are spill kits present and stocked with appropriate supplies?

  Yes

  No

  N/A

• Fire extinguishers are clearly marked (signage).

  Yes

  No

  N/A

• Fire extinguishers have been tested within the last year?

  Yes

  No

  N/A

• Fire extinguishers unobstructed.

  Yes

  No

  N/A

• Exits illuminated; clearly and correctly marked.

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Smoke/Fire Doors close freely.

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Proper stair identification signage at landings.

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Area is adequately lighted.

  Yes

  No

  N/A

• Sprinkler heads are free of foreign materials.

  Yes

  No

  N/A

• No unauthorized appliances (space heater, toaster).

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 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?

  Yes

  No

  N/A

• Eye wash maintenance is up to date?

  Yes

  No

  N/A

E. Chemical safety

• Chemicals stored properly.

  Yes

  No

  N/A

• Are hazardous liquids stored in below eye level?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Are potentially hazardous chemicals disposed of properly?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

F. Laboratory Equipment

• Equipment is clean and free from damage.

  Yes

  No

  N/A

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

  Yes

  No

  N/A

G. Fume Hoods

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

H. MISCELLANOUS

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

  Yes

  No

  N/A

• No food or drink in clinical work area.

  Yes

  No

  N/A

• Refrigerator temperature log completed and up to date.

  Yes

  No

  N/A

• Standards of cleanliness are maintained throughout.

  Yes

  No

  N/A

• HVAC vents free of dust.

  Yes

  No

  N/A

I. ADDITIONAL FINDINGS

• Is there any additional findings?

  Yes

  No

  N/A
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• Additionally findings 1:

• Is there any additional findings?

  Yes

  No

  N/A
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• Additionally findings 2:

• Is there any additional findings?

  Yes

  No

  N/A
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• Additionally findings 3:

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• Auditor

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