• Radiology / Imaging Department Audit

  • Conducted on

  • Prepared by

  • Personnel in Attendance:

1.0 General Area: Hand Hygiene

  • 1.1. Hand sanitizer is available and accessible for the patients and visitors in all waiting areas?

  • 1.2. Available liquid soap within all treatment rooms?

  • 1.3. Wall mounted paper towels available near each sink?

  • 1.4. Clinical staff able to demonstrate good handwashing techniques?

  • 1.5. Staff able to apply 5 moments of hand hygiene?

2.0 Patient Exam Rooms

  • 2.1. Floor and walls clean?

  • 2.2. Cubicle curtains unsoiled and free of tears?

  • 2.3. Exam table/bed is clean free of dust, rust, tapes and tape residues.

  • 2.4. Sink is clean and no supplies found within 3 feet of the sink in the absence of a splash guard.

  • 2.5. Liquid soap and paper towel dispenser are stocked and working?

  • 2.6. Alcohol hand sanitizers are available?

  • 2.7. Gloves, PPE available?

  • 2.8. No food or drink in patient care areas?

  • 2.9. Vent grill is dirt free?

  • 2.10. Wedges for positioning cleaned and disinfected after every patient use?<br>

  • 2.11. Drawers well organized and clean?

  • 2.12. Working surfaces are clean?

  • 2.13. Equipment decontamination done?

  • (Ultrasound) Pelvic Probe cleaned and disinfected per protocol

  • Ultrasound Tech can articulate cleaning and disinfection; transport and storage processes for pelvic probe.

  • 2.14. Mattress pad is without tears or puncture holes?

  • 2.15. Plants not present in clinical areas?

  • 2.16. (MRI) Cleaning equipment not containing any ferrous or ferromagnetic material?

  • 2.17. All surfaces on the MRI table (inside the magnet bore, magnet gantry and MRI coils is clean?

  • 2.18. Cleaning schedule is followed and updated?

  • 2.19. Is equipment properly cleaned per protocol/ manufacturer's recommendation?

3.0 Waste Management

  • 3.1. Waste containers clean, operational and in good condition?

  • 3.2 Waste containers covered and with labels?

  • 3.3. Contaminated instruments or disposables placed on designated area not mixed with clean items?

  • 3.4. Regulated medical waste discarded appropriately?

  • 3.5. Waste clearly segregated?

  • 3.6. Sharp containers secured and labeled appropriately?

  • 3.7. Sharp bins not mixed with any general/biomedical waste?

  • 3.8. Sharp containers are no more than 2/3 full?

  • 3.9. Staffs are aware not to bend, recap ore remove contaminated needle or sharps unless it is absolutely necessary?

4.0 Medications/ Items

  • 4.1. No outdated IV solutions, items and medicines?

  • 4.2. Open vials dated and times as per policy?

  • 4.3. Safe injection practices followed as per policy?

  • 4.4. Out of date sterile supplies are not present?

5.0. Utility and Storage Room

  • 5.1. Floors and walls clean?

  • 5.2. Horizontal and vertical surfaces are clean?

  • 5.3. Adequate separation of clean and soiled?

  • 5.4. Bottom shelf is solid?

  • 5.5. No supplies stored 10" from the floor?

  • 5.6. No supplies stored touching the 18" from the ceiling?

  • 5.7. No supplies stored in the dirty utility room?

  • 5.8 Soiled linen is bagged accordingly?

6.0. Chemical Safety

  • 6.1. Material Safety Data Sheets available for all chemicals?

  • 6.2. Risk assessments completed for hazardous substance?

  • 6.3. All containers labelled correctly?

  • 6.4. Unused substances disposed of?

  • 6.5. Do special storage conditions apply?

  • 6.6. Workers trained in the use of hazardous substance?

  • 6.7. If required is PPE available?

  • 6.8. Are eye washes and showers easily accessed?

7.0. Corridors/ Hallways/ Environment

  • 7.1. Furniture is clean and in a good state?

  • 7.2. The wall is clean and dust free?

  • 7.3. Free of obstruction and equipment?

  • 7.4. Reception area is clean and work surface clean and free from clutter?

Staff Knowledge on Infection Prevention

  • Staff able to articulate the hand hygiene the 5 moments of hand hygiene<br>

  • Staff able to articulate the care for instruments at point of care prior to transport to SPD

  • Staff able to articulate how an isolation patient is identified

Additional Comments

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