• Audit Title

  • Document No.

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel


  • Has the last audit been reviewed?

  • Are there any outstanding concerns?


  • ** Can you explain when you would implement R.A.C.E. (rescue, activate alarm, confine the fire, evacuate/extinguish)and what does it stand for?

  • ** Can you explain P.A.S.S. and what does it stand for?

  • ** Where are the fire extinguishers and pull stations located in your department?

  • Fire extinguishers and pull stations clear of obstructions?

  • Fire extinguisher (s) recently serviced? (monthly)

  • Fire extinguisher < or =75'

  • Two exit signs visible from each corridor with appropriate arrow direction?

  • Halls/Corridors uncluttered and accessible?

  • Are ceiling tiles in place / not damaged?

  • Are the sprinkler heads free of dust?

  • Automatic fire doors free from obstacles and positively latch when activated? (Doorways should not be blocked or wedged.)

  • Eighteen-inch clearance from sprinkler head ensuring no obstruction?

  • Are compressed gases stored in designated areas only and less than 12 cylinders per smoke compartment?

  • Are oxygen cylinders properly segregated and in proper storage?

  • All lights are working properly?

  • Flammable and hazardous materials properly stored and labeled?

  • Placement of Hand Sanitizer (>6" from electrical outlet and not directly above an electrical outlet)?

  • Exits clear of obstructions?

  • Evacuation routes posted and current

  • WOWs servers/charting surfaces kept secure when not in use

  • Equipment located on one side of the aisle?

  • Smoking policy enforced?


  • Electrical safety checks performed by Facilities as required?

  • Electrical cords, plugs, plates and switches are in good repair?

  • Extension cords are not in use except where permitted?

  • Use of potable heating devices prohibited in patient treatment areas; except physician-ordered treatment devices?

  • Portable heating devices prohibited in employee areas except when approved by facilities (non sleeping staff and employee areas and heating elements <212 deg.)?

  • The underside of beds and counters are free of electrical “wire nests” where feet could be entangled?

  • Blanket Warner's safely used (correct temperature setting <=130 deg., not overloaded, adequate clearance on bottom rack, etc.)


  • ** How can you access Material Safety Data Sheets (MSDS)?

  • ** Do you know where your PPE is located?

  • When corrosive chemicals are present, is there a portable eye was station available (within 15 second access uninstructed), operable, and tested/checked weekly?

  • Sharps containers are in proper location and secure?

  • Sharps containers contain appropriate material (ie. no gloves, gauze and tubing.)

  • Items in BioHazardous Waste box is appropriate?

  • Containers properly labeled (identity and hazard warnings)?


  • Handrails accessible and properly secure?

  • Work Surface Clean

  • Wet floor signs available and used?

  • Code cart is locked, neat and tidy?

  • Emergency cart/drug box/defibrillator checks are current.

  • All furniture and equipment is in sound condition? (no chipped or torn surfaces- no leaky faucets)

  • Refrigerator/freezer temperature checks are current?

  • Expiration dates checked (meds, food, supplies)?

  • Cleaning chemicals are properly labeled and are not accessible by residents and visitors?

  • Patient care items/supplies are not stored directly on the floor?

  • Items are not stored under sink(s)? (If items found - list in comment section)


  • ** How do you notify Security in a non-emergency?

  • Employees, volunteers, students, contracted staff, physicians, contractors and venders wearing ID badges @ eye level?

  • Are valuables properly stored in department?

  • Are latches on Patient doors in working order with emergency access?

  • Rooms/offices secure when unattended?

  • Panic alarms present/functioning?


  • Floors free of dirt, dust and litter?

  • Ledges, walls and air vents free of dust?

  • Toilets and sinks secure?

  • Privacy curtains clean and unsoiled?

  • Ventilation, temperature/humidity levels suitable for patient care?


  • ** Can you tell me the number you would dial to initiate an emergency response?

  • Are Emergency light (Flashlights) available?

  • **Staff can identify the location of the hospital Emergency Operations Plan.

  • **Staff can identify correct actions to take in a Code Gray (tornado) situation.

  • **Staff can identify correct actions to take in a Code Pink (abduction) situation.


  • Staff food is not stored in patient refrigerators?

  • No open or expired patient nourishment containers in refrigerator?

  • Ice machines are clean, no signs of deposits in tray or dispensing mechanism?

  • Refrigerators/Freezers are clean, frost free, and labeled for type of storage with only those items present (no food and medication in the same refrigerator).

  • Anti-microbial soap and paper towels are available for hand washing?


  • ** What are the procedures if a device/equipment does not work properly OR if the device is involved in a resident related incident?

  • All medical equipment/devices has a current Bio-Medical sticker?


  • ** Where are your emergency backup procedures located for a loss of utility services?

  • ** In case of a fire on the unit, who is authorized to shut off medical gases?


The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.