Wet Procedure Location Assessment

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Location
  Address

• How many procedures are performed at these locations per year?

• Assessment Group Members

• Have there every been incidents of electrical shock to staff or patients in these areas?

  Yes

  No

  N/A

• Were the incidents investigated by qualified safety personnel (i.e. Patient Safety, Hospital Safety Officer?

  Yes

  No

  N/A

• What was the root cause and what corrective actions were implemented to prevent reoccurrence?

Assessment Questionnaire

• Does surgical staff perform procedures that generate standing fluid on the floor?

  Yes

  No

  N/A

• Do surgical staff perform procedures that generate drenching of the work area?

  Yes

  No

  N/A

• Are extraction systems available to reduce the liquid on the floor?

  Yes

  No

  N/A

• Are line power cords on the floor within six (6) feet of the patient or line power suspended from the ceiling that could reach within six feet of the patient?

  Yes

  No

  N/A

• Are line cords, attachment plugs, and exposed metal routinely inspected, repaired or taken out-of-service until fixed?

  Yes

  No

  N/A

• Is a visual inspection of all equipment completed before starting any surgical procedure?

  Yes

  No

  N/A

• Does medical electrical equipment comply with IEC ANSI/AAMI ES60601-1?

  Yes

  No

  N/A

• Do you have procedures to manually contain or remove fluids during a procedure (i.e. absorbent pads)?

  Yes

  No

  N/A

Hospital Safety Officer

• Comments

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