WCGH Safety Rounds Report

• Department/Office

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Address
  Address

• Are all employees/medical staff wearing their ID badges in plain view? Provide #’s below:

  Yes

  No

  N/A

• # Wearing Badge:

• # Not Wearing Badge:

Section A. General Safety

• Employees can verbalize procedures for reporting unsafe situations, equipment, and other safety concerns

  Yes

  No

  N/A

• Floors, vents, curtains/blinds, walls, work surfaces, and furniture are clean and free of tears, or cracks

  Yes

  No

  N/A

• Compressed gas cylinders (oxygen, etc.) are properly stored. [All tanks secured; less than 300 cu ft. O2 in area (i.e.12 E tanks; full tanks not in same rack as partial/empty tanks, etc.]

  Yes

  No

  N/A

• Floors clear of tripping hazards/spilled liquids/stains

  Yes

  No

  N/A

• Employees can state the location and procedure for 02 shut off

  Yes

  No

  N/A

• O2 question tallies: # Yes

• O2 question tallies: # No

• Integrity of floor mats: Are mats intact?

  Yes

  No

  N/A

• Are there expired materials/supplies on hand?

  Yes

  No

  N/A

• Integrity of wooden surfaces (tables, chairs, railings etc.) intact

  Yes

  No

  N/A

• Are all patient medical records/patient information in a secured location?

  Yes

  No

  N/A

• Are ceiling tiles clean, stain free, and in good condition?

  Yes

  No

  N/A

• Eye wash stations have been inspected and are unobstructed

  Yes

  No

  N/A

Section B. Electrical Safety

• Employee are in-serviced as new equipment arrives. Documentation is present

  Yes

  No

  N/A

• Are electrical cords and plugs free of damage or fraying?

  Yes

  No

  N/A

• Access to electrical panels is clear – no storage within 3 feet of panel

  Yes

  No

  N/A

• Electrical outlets are in good condition

  Yes

  No

  N/A

• All biomedical equipment has inventory inspections are up to date

  Yes

  No

  N/A

• Electrical equipment is clear of tools, paper, refuse and clutter

  Yes

  No

  N/A

• Are permanent extension cords in use?

  Yes

  No

  N/A

• All nonclinical electrical equipment in patient care areas have initial safety inspection checks

  Yes

  No

  N/A

Section C. Safety Management Program

• Employees can located the WCGH safety policies in department or on line

  Yes

  No

  N/A

• The SDS chemical inventory is current

  Yes

  No

  N/A

• Chemical containers are properly labeled

  Yes

  No

  N/A

• Employees can articulate their role in a disaster (Code Triage)

  Yes

  No

  N/A

• Employees can locate and answer questions pertaining to Department SDS

  Yes

  No

  N/A

• SDS question tallies: # Yes

• SDS question tallies: # No

Section D. Fire Safety

• Employees can verbalize R.A.C.E. /PASS

  Yes

  No

  N/A

• Sprinkler heads are free of dust or foreign materials/escutcheons are present

  Yes

  No

  N/A

• Employees can locate fire extinguishers, pull stations and fire exits

  Yes

  No

  N/A

• Life Safety question tallies: # Yes

• Life Safety question tallies: # No

• Is storage closer than 18 inches to bottom of sprinkler head (20 inches from ceiling)?

  Yes

  No

  N/A

• Stairwells, doorways and hallways are free of obstruction

  Yes

  No

  N/A

• Doors with auto-latching verified to self-close and latch; all door latch appropriately when closed

  Yes

  No

  N/A

• Employees can identify emergency lighting and outlets

  Yes

  No

  N/A

• Is smoke resistant sealant used on corridor walls and doors?

  Yes

  No

  N/A

• Exit signs are illuminated. Emergency lights work. Back-up batteries work (Hit the test button if available)

  Yes

  No

  N/A

• Are plugs for holiday decorations plugged directly into an outlet (i.e. no stacked plugs)

  Yes

  No

  N/A

• Doors close freely and are not held open by wedges

  Yes

  No

  N/A

• Are sprinkler heads free of dust or other foreign material? Is escutcheon present?

  Yes

  No

  N/A

• Fire Extinguishers and pull stations are unobstructed

  Yes

  No

  N/A

• Are all holes and other openings in walls fire stopped? Is I-Beam insulation intact?

  Yes

  No

  N/A

• All fire extinguishers are tagged and checked monthly

  Yes

  No

  N/A

• Are all high amp drawing appliances like refrigerators, coffee makers, etc. plugged directly into the wall?

  Yes

  No

  N/A

• Is equipment and supplies stored on the floor?

  Yes

  No

  N/A

• Are vitals or other machines being charged in hallway(s)?

  Yes

  No

  N/A

Section E. Cleanliness, Infection Control, Clinical Inspection Items

• Patient and exam rooms are clean. (No visible dust on surfaces)

  Yes

  No

  N/A

• Are patient contact items, food stuffs, bottled water containers stored on the floor?

  Yes

  No

  N/A

• Sharp containers are securely installed, locked tops fit correctly, and not overfilled

  Yes

  No

  N/A

• Is there storage in under sink cabinets (only chemicals allowed)

  Yes

  No

  N/A

• Clean linen kept separate from soiled linen disposal. /Clean linen is covered

  Yes

  No

  N/A

• All upholstered surfaces (i.e. wheelchairs, exam tables, stool, chairs, etc.) are intact – no rips, tears

  Yes

  No

  N/A

• Adequate amount of soap and paper towels at each sink and treatment area

  Yes

  No

  N/A

• All casters on equipment in patient areas are in good shape (not rusted)

  Yes

  No

  N/A

• All medications/needles/syringes kept in locked rooms/locations

  Yes

  No

  N/A

• Code Cart and Pediatric Cart Logs are current and complete

  Yes

  No

  N/A

• Refrigerators/Thermometers - Refrigerators are clean. Medications/Specimens labeled/ dated appropriately. No Food/Drink storage in medication/specimen refrigerator. Temperatures are checked and logged. Thermometer is calibrated.

  Yes

  No

  N/A

• MD Practices: Betadine, hydrogen peroxide, isopropyl alcohol bottles date/time/initials when opened & discarded 12 months or manufactured expiration date whichever is sooner. Hospital patients -- date/time/initial small bottles dispensed and discarded or sent home with patient.

  Yes

  No

  N/A

• Personal protective equipment is available/used

  Yes

  No

  N/A

• Emergency Call Light Cord in bathroom not touching floor, is not too short (can be reached from someone on floor), not tied to grab bar

  Yes

  No

  N/A

• All multi-dose vials dated when opened dated/timed/initials & discarded within 28 days (includes medications)

  Yes

  No

  N/A

Section F. Safety Tour Deficiencies Notes

• Were additional deficiencies found? (See note for details)

  Yes

  No

  N/A

• Additional Tour Notes