Safety Rounds conducted for UPMC Hamot Document No. Audit Title 3 Main / West Conducted on 8:15 10/23/12 Prepared by Ramsey Personnel Ramsey, Moryc Completed on 13:52 10/26/12
Table of Contents SAFETY ROUNDS 1 AUDIT 3 Fire Prevention 3 Security Management 4 Log Sheet Documentation 4 Safety Management 4 Utilities Management 5 Clinical Equipment 5 Hazardous Materials 5 Infection Control 6 Waste Management 6 Recommended Follow-up? 7 MEDIA 8-2 -
Audit Fire Prevention Question Response Details Fire doors close and latch? Smoke doors close? Doors wedged? At Risk IV team store room Locker Room IV Team Break Room Appendix 1 Appendix 2 Appendix 3 Appendix 4 Exit signs illuminated? Fire alarms accessible? Fire extinguishers accessible? Flammables stored appropriately? No Paper products stored against outlet used for appliances Appendix 5 Medical gas stored appropriately? No Unsecured cylinder Appendix 6-3 -
Question Response Details Appropriately Use of bulk medical gas storage rooms? Smoke detectors unobstructed? Sprinklers unobstructed? Appropriate use of decorations? Fire and smoke barrier penetrations sealed? N/A No Data closet on 3 West Appendix 7 Security Management Medications secured? No Syringes and needles secured? No IV flush syringes unattended - nurse's station Medical records secured? Staff wearing IDs? Belongings secured? Log Sheet Documentation Crash carts - daily? No Missing multiple days Refrigerators - daily? Fire Extinguishers - monthly? No No temp logs on refrigerators in 3 Main or 3 West Safety Management Electrical cords and plugs in a safe condition? Extension cords are not in use? - 4 -
Question Response Details GFI outlet within 6' of water source? Electrical panels accessible (3')? Corridors unobstructed? No Items in 3 Main Emergency reference guides available? Flashlights available? Lifting equipment available? Stairwells clear? Step stools available? Storage and mechanical rooms clean? Utilities Management Ceiling tiles stained? At Risk Locker Room 3 West South Hall Appendix 8 Appendix 9 Oxygen shut off valves labeled? Clinical Equipment Current PM sticker? Alarms disabled? Hazardous Materials Safe - 5 -
Question Response Details Appropriate use of utility rooms? No Items should be removed from this telephone closet. Honeywell panel should have the cover replaced. Appendix 10 Appendix 11 Sharps containers overfilled? PPE available? Products properly labeled and stored? Infection Control Hand-washing observed? Isolation precautions followed? Linen covered? Safe General infection control conerns At Risk Items stored directly on floor - PPO Storage Appendix 12 Appendix 13 Appendix 14 Waste Management Appropriate items in RCRA Cans (Warfarin) Appropriate items in red bags? Appropriate items in sharps container? Appropriate items in general trash? Appropriate handling of waste streams? - 6 -
Question Response Details Recommended Follow-up? Follow-up for manager? 3 Main 1) Ensure that the crash cart is being checked on a daily basis. 2) Remove items from the corridor. 3) Ensure medications are secured. 4) Crash carts should be checked on a daily basis. 5) Secure all oxygen cylinders. 6) Doors can not be wedged IV Team. 3 West 1)Educate staff about not wedging doors. (IV Team) 2) Move paper products away from the electrical outlet under the counter in the IV Team Breakroom. Follow-up for Facilities? 1) Remove items from the floor in the two Physical Planning Storage Rooms. 2) Replace ceiling tiles on 3 west. 3) Re-key the lock on 3 Main for medication storage and provide the staff with a new key. 4) Seal hole in fire wall in the 3 West Telecom. Closet. - 7 -
Media Appendix 1 Appendix 2 Appendix 3 Appendix 4-8 -
Appendix 5 Appendix 6 Appendix 7 Appendix 8-9-
Appendix 9 Appendix 10 Appendix 11 Appendix 12-10 -
Appendix 13 Appendix 14-11 -