Surveyed by: Dept. surveyed: Dept. Manager:
Date: Location: Phone: _____________________ Fax: _________ Box:_________
FACILITY / SAFETY ROUNDS 2001 CHECKLIST SAFETY ITEM Staff aware that lift team is available. Staff can demonstrate how to lift properly? Staff know what to do if stuck by a needle, splashed or exposed to body fluids? What do you do if you’re injured on the job? Staff know how to report a safety problem? Refrigerators are clean, defrosted, clearly labeled as to use, have thermometers and are checked on a daily basis on inpatient units? (PATIENT CARE ONLY) Department EC Plan in the Environment of Care manual is complete & is current (within 12 months). Who is the Medical Center Safety Officer? Staff know how to activate "Code Blue?" Staff know location of Environment of Care (Safety) Manual?
CORRECT RESPONSE
OK
NOT OK
DESCRIPTION
Yes. Lift team pager #’s Parnassus: 719-4677, 3683
Yes. Bend at knees. Do not twist. Rinse with soap and water. Call Needlestick Hotline @ 719-3898. Notify supervisor. Call Employee Health @ 885-7580 to get appt. for treatment. Notify the Safety Officer @ 885-3538. Call EH&S @ 4761300. Tell supervisor. Yes. Temperature log shows daily checks.
Yes.
Robert Hunn Yes. Dial 6-1234 (Parnassus) or 5-1234 (Mount Zion). Yes. They can show you where it is located.
Printed on 6/25/02 Items in bold are being tracked for comparison against performance standards.
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Surveyed by: Dept. surveyed: Dept. Manager:
Date: Location: Phone: _____________________ Fax: _________ Box:_________
FACILITY / SAFETY ROUNDS 2001 CHECKLIST
SAFETY (Cont) ITEM Do you know where TB cart is or how to get one if needed? (Inpatient only) What is the correct mask for you? Is this information on your ID Badge?
CORRECT RESPONSE
OK
NOT OK
DESCRIPTION
If a TB cart is not on the unit they are obtained from Materiel Mgmt. (Inpatient only) Staff should name type and size of N-95 that they were fit-tested for. Look for respirator sticker on badge.
Printed on 6/25/02 Items in bold are being tracked for comparison against performance standards.
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Surveyed by: Dept. surveyed: Dept. Manager:
Date: Location: Phone: _____________________ Fax: _________ Box:_________
FACILITY / SAFETY ROUNDS 2001 CHECKLIST
SECURITY ITEM
CORRECT RESPONSE
Staff know whom to call if a person is acting violently? Staff know what "Code Pink" is and how to respond? (Moffitt/Long Hospitals)
Dial 9+911
Specialized alarms, security systems, panic buttons, and cameras working?
Yes.
OK
NOT OK
DESCRIPTION
(Pink)Suspected infant abduction. Watch hallways & elevators for suspicious persons, and report to 9+911. (Inpatient only) (Grey) Security Staff know what “Code incident: Trained Gray” is and how to personnel respond, respond? others clear area. Are personal items locked up Yes. & secured? Staff know 24 hour phone Yes. 885-7890 number for security request? All staff is wearing current Yes. Staff without photo ID badges in an incurrent ID’s are to be patient area. directed to Medical Center Security.
Printed on 6/25/02 Items in bold are being tracked for comparison against performance standards.
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Surveyed by: Dept. surveyed: Dept. Manager:
Date: Location: Phone: _____________________ Fax: _________ Box:_________
FACILITY / SAFETY ROUNDS 2001 CHECKLIST
HAZARDOUS MATERIALS ITEM Food items and hazardous materials are segregated? Does the responsible person know how to secure sharps boxes and where to dispose of them? Gas cylinders are secured, and stored in the designated area.
Staff know whom to call for hazardous materials spill? What is an MSDS sheet? Staff know how to find MSDSs? Labels on chemical containers are legible & identify contents/ hazards?
CORRECT RESPONSE
OK
NOT OK
DESCRIPTION
Yes. Yes. Have them describe or demonstrate. Yes. -stored & secured in a designated area -no cylinders in corridors -cylinders “off” at zero pressure while in storage 9+911. UCPD will dispatch emergency response team. Material Safety Data Sheet. Found in EC manual, EH&S, and on the Web. Yes.
Printed on 6/25/02 Items in bold are being tracked for comparison against performance standards.
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Surveyed by: Dept. surveyed: Dept. Manager:
Date: Location: Phone: _____________________ Fax: _________ Box:_________
FACILITY / SAFETY ROUNDS 2001 CHECKLIST
EMERGENCY PREP ITEM
CORRECT RESPONSE
OK
NOT OK
DESCRIPTION
Staff know their role in "Operation Triage?"
Yes. Department assignment or report to personnel pool. What number would you call 9+911 in an emergency? Staff can describe the departments Emergency Power capabilities and/or procedures. "Emergency Conditions and Yes. It's the multiBasic Staff Response" chart layered "rainbow" chart. is posted? Where is the nearest emergency phone? How is it used? What does “Facilities Mobilization” mean?
Utility failure. No elevators, no water etc.
Staff know Medical Center Disaster Hotline number.
Yes. 885 STAT
Printed on 6/25/02 Items in bold are being tracked for comparison against performance standards.
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Surveyed by: Dept. surveyed: Dept. Manager:
Date: Location: Phone: _____________________ Fax: _________ Box:_________
FACILITY / SAFETY ROUNDS 2001 CHECKLIST
FIRE/LIFE SAFETY ITEM
CORRECT RESPONSE
OK
NOT OK
DESCRIPTION
Laterally to the next “area of refuge” which is the area beyond the fire doors. Or exit building through the nearest exit (refer to e/c plan for specific site plan) Where is your evacuation Staff should identify map for your area? location of an evacuation map/plan posted on wall. What does R A C E mean? Rescue people (in relationship to a fire) Announce: Pull alarm & call 9+911 Contain the fire Extinguish, if safe Staff can describe what to do Follow department if a fire alarm is triggered in specific instructions. an area other than their own. Area below ceiling w/in 18" Yes. (Check storage of sprinkler heads is clear? areas.) Yes. Tag should be Fire extinguisher available dated within last 30 w/in 75 ft. & inspection tag days. up to date? Emergency exits clear of Yes. obstruction? If the area were on fire, where is the nearest area of refuge?
Printed on 6/25/02 Items in bold are being tracked for comparison against performance standards.
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Surveyed by: Dept. surveyed: Dept. Manager:
Date: Location: Phone: _____________________ Fax: _________ Box:_________
FACILITY / SAFETY ROUNDS 2001 CHECKLIST
MEDICAL & ELECTRICAL EQUIPMENT ITEM How would you handle a piece of equipment that may have contributed to patient injury?
What system do you use for insuring malfunctioning equipment is taken out of service and repaired. All electronic medical equipment is grounded, has hospital grade plugs – 3prong style. Cords are intact, not frayed, corroded or exposed to excessive heat? Extension cords are NOT in use?
If autoclave present, is inspection tag dated within the last year? Is autoclave QC record available?
CORRECT RESPONSE
OK
NOT OK
DESCRIPTION
Complete an incident report and attach pink copy to equipment. Keep all disposables used with the equipment and notify Clinical Engineering. Fill out red tag, attach to equipment, set equipment aside and call Clinical Engineering. (check red tag supply) Yes. All equipment has U.L. listed Hospital Grade plugs. Yes. Usually Yes. Heavy duty hospital grade extension cords may be allowed in some areas (i.e. Ors) if approved by Clinical Engineering. Yes. Yes. Ask to see log.
Printed on 6/25/02 Items in bold are being tracked for comparison against performance standards.
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Surveyed by: Dept. surveyed: Dept. Manager:
Date: Location: Phone: _____________________ Fax: _________ Box:_________
FACILITY / SAFETY ROUNDS 2001 CHECKLIST
FACILITIES ITEM Staff know how to report a Facilities related problem? Supervisor knows location of medical gas shutoff valves? Staff know circumstances under which oxygen would be shut off? Staff can identify backup/emergency power electrical outlets? What is Code Dry? What do you do during a Code Dry?
Where are the medical shut off valves? Are the medical gas shut off valves labeled with location/room numbers? Do all laundry chutes and trash chutes positively latch? Electrical panels have three feet of clearance in front? Do the cross-corridor fire doors close properly?
CORRECT RESPONSE
OK
NOT OK
DESCRIPTION
Parnassus 353-1120 ACC 353-2261 MZ 885-7576 Yes. (Inpatient only & all surgery areas) By clinical charge person & only upon direction of fire/building officials. They are red. Water Shortage. Conserve water, don’t flush toilets. Triple red bag toilets for human waste. Yes, medical gas shut off valves are labeled. They can show you were the medical gas shut off valves are. Yes. Yes. They are red or grey metal doors in walls or electrical closets. Yes.
Printed on 6/25/02 Items in bold are being tracked for comparison against performance standards.
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Surveyed by: Dept. surveyed: Dept. Manager:
Date: Location: Phone: _____________________ Fax: _________ Box:_________
FACILITY / SAFETY ROUNDS 2001 CHECKLIST Are all the exit lights illuminated?
Yes.
Printed on 6/25/02 Items in bold are being tracked for comparison against performance standards.
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Surveyed by: Dept. surveyed: Dept. Manager:
Date: Location: Phone: _____________________ Fax: _________ Box:_________
FACILITY / SAFETY ROUNDS 2001 CHECKLIST
INFECTION CONTROL ITEM Infection Control Manual TB Exposure Control Plan
Personal Protective Equipment (PPE)
Engineering Controls
Work Practice Controls
CORRECT RESPONSE
REGS
• Available • Current date • Staff know how to access Infection Control website: http://infectioncontrol.ucsfmedica lcenter.org • Gloves – vinyl/latex • Masks • Gowns • Eye/face shield • Resuscitation Mask (1-wayvalve)/ambubag • Sharps container; less than ¾ full • Accessible • Safety devices available and used • No eating/drinking in patient care or specimen handling areas
OSHA Title 22 70739 HCFA
OK
NOT OK
DESCRIPTION
OSHA CDC Title 22 70739
OSHA Title 22 70843
OSHA Title 22 70739
Printed on 6/25/02 Items in bold are being tracked for comparison against performance standards.
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Surveyed by: Dept. surveyed: Dept. Manager:
Date: Location: Phone: _____________________ Fax: _________ Box:_________
FACILITY / SAFETY ROUNDS 2001 CHECKLIST
INFECTION CONTROL ITEM Supplies
Linen/Laundry
CORRECT RESPONSE
REGS
• Sterile items stored to maintain integrity of package in a clean dry area • Clean dry dust free environment • Stored 8-10 inches off floor • Stored 18 inches away from ceiling • Clean linen maintained in a clean/dry area and covered • Soiled linen stored in covered container with labeled lid
Title 22 70831
OK
NOT OK
DESCRIPTION
Title 22 70825
Printed on 6/25/02 Items in bold are being tracked for comparison against performance standards.
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Surveyed by: Dept. surveyed: Dept. Manager:
Date: Location: Phone: _____________________ Fax: _________ Box:_________
FACILITY / SAFETY ROUNDS 2001 CHECKLIST
INFECTION CONTROL ITEM Clean Utility Room If it is impossible to separate clean and dirty utility rooms, every effort is made to keep sterile items separated from dirty items/functions by space and/or enclosures. Soiled Utility Room
CORRECT RESPONSE
REGS
• Signage identifies as clean • Hand washing/sink supplies available • No food/drink • No contaminated items in area • Environment is clean orderly • PPE is available and used appropriately • Sink for washing/soaking contaminated instruments available • Enzymatic cleaner available • Container with soaking solution is covered • Disinfectants labeled, dated when (if) reconstituted
OSHA Title 22 70831
OK
NOT OK
DESCRIPTION
OSHA Title 22 70739 70843 70845 70847
Printed on 6/25/02 Items in bold are being tracked for comparison against performance standards.
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Surveyed by: Dept. surveyed: Dept. Manager:
Date: Location: Phone: _____________________ Fax: _________ Box:_________
FACILITY / SAFETY ROUNDS 2001 CHECKLIST
INFECTION CONTROL ITEM Patient Exam Room
Healthcare Workers Describe
CORRECT RESPONSE
REGS
• Linen enclosed/covered • Exam table – paper changed between patients/cleaned with disinfectant when soiled • Disinfectant available • No patient care items under sink • Environment is clean and orderly • Universal/Standard Precautions • Location of Infection Control Manual • Location of PPEs and respirators • Disposal of biologicals/vaccines
OSHA Title 22 70739 70825 70831 70843 70845
OK
NOT OK
DESCRIPTION
OSHA Title 22 70739 CDC
Printed on 6/25/02 Items in bold are being tracked for comparison against performance standards.
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