QUALITY ROUNDS FORM

By:_________________ Date:________________
Area:________________________________________

OBSERVATIONS
PATIENT SAFETY
N
# Quality Rounds Criteria Met
Not
Met A

1. Medication's refrigerators temperature is monitored on daily basis evident by clear staff signature. (O)
2. Multi dose vials are labeled with the date of opening and the date of expiry and staff knows the outdating
guidelines. (O)
3. High alert medications are stored secured in a manner that restricts access and prevent inadvertent
administration and labeled.(O)
4. Patients' bathroom is safe and provided with alarm system to call nurses in case of emergency while he in
the bathroom. (O)
INFECTION CONTROL
5. Good General cleanliness of the unit. (O)
6. Hand washing or hand rubbing practice is applied according to observation of opportunities for hand
hygiene. (O)
7. Personal protective equipment is available in the patient care area and ready for use in case of standards
or isolation precautions. (O)
8. Sharp containers are maintained according to policy and the staff knows the process of disposal. (O/D/I)
9. Outdating of antiseptics and solutions is registered on the containers. (O)
10. Soiled linen area is clean and in order, containers are closed and are not full. (O)
11. Cleaner trolley is in order and chemicals are dated for opening and labeled. (O)
12. Big Carton containers are not available in the stores. (O)
13. Food refrigerator's Temperature is monitored on daily basis and contains food only. (O)
GENERAL SAFETY
14. MSDS sheets are available for every hazardous and chemical material available in the unit. (O)
15. There is implemented process to store and use of dangerous chemicals like formalin and cidex. (O)
16. Oxygen cylinders is secured and placed in a safe manner. (O)
17. Stores are well maintained and in order – items are labeled by items and with the most recent items expiry
date. (O)
18. Storage is below the ceiling 45 CM & No storage on the floor (O)
19. Calibration and Preventive Maintenance Labels are Current on All Medical Equipments in the unit. (O)
20. Spill kits are available and the staff knows how to use it in response to chemical or blood spills. (O/D/I)
21. Staff in the unit is wearing their ID Badges. (O)

REVIEW
PATIENT SAFETY
N
# Quality Rounds Criteria Met
Not
Met A

22. Verbal telephone orders are written according to policy and counter signed within 24 hours.(R)
23. Site marking procedures and time out is documented correctly in the patient file. (O/R)
24. Patients are assessed for risk for fall initially on admission and on daily on each shift. (R)
25. When the risk of fall is low moderate or high the goal is written in the care plan and interventions
are documented in the nursing progress note. (R)
26. Medications brought by patients or taken before admission are written in the initial physician
assessment sheet and re-conciliated to the medications prescribed during hospitalization. (R)
27. Narcotic and controlled substances are accounted according to hospital policy. (R)
GENERAL SAFETY
28. Emergency carts are secured and maintained on regular basis evident by signed check sheet for
medications and equipment. (R)
29. Laboratory test producing equipment such as Gluco Check, ABGs and ACTs Are well maintained
and the quality of results is overseen by laboratory services evident by written reports, quality
control sheets and log books. (R)
QUALITY AND GENERAL PROGRAMS
30. Consents are documented completely and signed clearly by the patient, physician and a witness.
(R)
31. Initial nursing assessment of a selected patient file is completed and reflects the patient's needs
on admission. (R)
32. Pain assessment and management by nurses is documented. (R)
33. Nursing care Plan is reflecting the patient needs assessed and re-assessed during hospital stay.
(R)
34. Plan of care is written in a form of measurable goals. SMART (R)
35. Nurses educate patients on the medications administered to them during hospitalization which
evident by documentation on interdisciplinary patient and family education form. (R)
36. Initial physician assessment form is completed and signed by the assistant and consultant had
completed and signed the consultant review note. (R)
37. Plan of care is documented by physician in the initial physician assessment form in a form of
measurable goals. (R)
38. Discipline Plan of Care is reviewed by the MRP (R)
39. patients of acute care has daily progress notes in their medical records (R)
40. Post operative orders are written in the physician order sheet and signed by the responsible
surgeon. (R)
41. Operative report is completed and signed by the responsible surgeon. (R)
42. Staff can identify the list of DONOT USE Abbreviations and can find the Approved list of
Abbreviations on the drop box. (R)
43. Staff can demonstrate who to correct errors of entries in the medical records. (R)
44. Staff signatures are clear and contain the ID number. (R)
45. Patient's medical record is kept far way from public handling and has restricted access. (R)
46. Consultant has at least 3 progress notes Per week in the medical record that approves the
assessment and plan of care made by his assistants and other healthcare practitioners. (R)
 DEMO / INTERVIEW
PATIENT SAFETY
N
# Quality Rounds Criteria Met
Not
Met A

1. Patient room environment promotes patient safety and nurses oriented patient well to his room and its utilities. (D/I)
2. Read back process for verbal telephone orders, critical values, critical results is well known and implemented.(D/I)
3. Measures to prevent wrong site, wrong procedure and wrong patient surgery are well known and applied by staff.
(D/I)
4. Staff can verbalize the indication of time out procedure.(D/I)
5. Staff can demonstrate the safety actions to look alike and sound alike medications. (D/I)
6. Staff can verbalize the procedures of ordering and assessing the safety of patient's restraints. (D/I)
7. Staff is able to unlock the patient's bathroom. (D)
8. Staff can verbalize the definition of sentinel event and can demonstrate its management process. (D/I)
INFECTION CONTROL:
9. Staff can verbalize the process of reporting and managing needle sticks. (D/I)
10. Staff can verbalize the proper medical waste segregation and the dirty utility room is clean and in order. (D/I)
11. Isolation precautions are well known to staff and the posters are ready in the unit. (D/I)
12. Nurse can verbalize the standard precautions for dealing of airborne diseases such as T.B. (D/I)
13. Staff can verbalize the testing of negative pressure rooms and show how they document the testing on daily basis.
(D/I)
GENERAL SAFETY:
14. Emergency codes for internal disasters are well known and the staff can verbalize the response actions for each code.
(D/I)
15. Staff can verbalize their responsibilities regarding the response to external disaster alerts. (D/I)
16. Staff can verbalize the procedure of RACE & PASS. (D/I)
17. Staff can lead to nearest fire extinguisher and demonstrate actions in case of detecting fire or smoke. (D/I)
18. Staff can identify the exit doors and track the emergency exits in case of evacuation. (D/I)
19. Staff can verbalize their responsibility in the event of unit horizontal and vertical evacuation. (D/I)
20. Chemicals are stored in safe cabinets and labeled by the clear name and the date of opening and the staff knows the
date of outdating after the date of opening. (O/D/I)
21. Staff knows their responsibilities toward medical gases in case of fire. (D/I)
22. Staff can verbalize the process that they can estimate the time of O2 THERAPY according to the volume in the
cylinder. (I)
23. Staff can locate the outlets of Main electricity source and the outlets of the generator and UPS. (D/I)
24. Staff can demonstrate operating medical equipments according to their responsibilities. (D/I)
25. Staff can verbalize the process when medical equipment did not function well. (D/I)
QUALITY AND GENERAL PROGRAMS:
26. Staff can describe the departmental orientation program that provided to him / her during the probationary period. (I)
27. Staff can describe the competency assessment program in the department that evident in his educational file. (I)
28. Staff is aware of patients and families rights and responsibilities. (D/I)
29. Patients and their families are aware of their rights and responsibilities. (I)
30. Staff can provide information about the scope of service of the department and the most frequent types of patient's
diagnosis admitted to their units. (I)
31. Staff can describe in brief departmental quality program in his department. (I)
32. Staff can describe the last performance improvement project carried out in the department. (I)
33. Staff can demonstrate knowledge of implemented quality monitoring indicators. (D/I)
34. Staff can access to the intranet drop box containing hospital wide and departmental plans, policies and procedures.
(D/I)
35. Staff can demonstrate the process of occurrence variance accident reporting. (D/I)
36. Staff can verbalize when to re-assess patient's pain after administering pain medications. (I)
Legend: (R) – Review (D/I) – Demonstration/Interview (O) – Observation

Safety Department
 ‫‪LIFE SAFETY MONITORS CHECKLIST‬‬

‫‪UNIT:‬‬ ‫‪DATE:‬‬

‫‪#‬‬ ‫‪YES‬‬ ‫‪NO‬‬ ‫‪NA‬‬

‫‪1.‬‬ ‫االدراج وابواب الحريق تغلق بشكل الي ‪/‬بشكل كامل‪/‬ال يوجد ما يعيق اغالقه آليا‬

‫‪2.‬‬ ‫مخارج الطوارئ والطريق الى المخارج سالكة وآمنة وال يوجد أي عائق‬

‫‪3.‬‬ ‫الطفايات اليدوية مفحوصة بشكل شهري ونصف سنوي وتعمل بصورة جيدة‬

‫‪4.‬‬ ‫تم فحص نظام االنذار واالطفاء ويعمالن بشكل جيد‬

‫‪5.‬‬ ‫يوجد مسافة ‪ 45‬سم بين المرشات المائية والمواد‬

‫‪6.‬‬ ‫التخزين آمن وال يوجد شيء على االرض‬

‫‪7.‬‬ ‫ال يوجد ثقوب وفتحات في جدران الحريق‬

‫‪8.‬‬ ‫االسالك الكهربائية والمخارج الكهربائية سليمة‬

‫‪9.‬‬ ‫الوصالت الكهربائية غير مستخدمة‬

‫‪10.‬‬ ‫ال يوجد اوساخ او تلف في السقف المستعار‬

‫‪11.‬‬ ‫اضاءات المخارج مضاءة ومفحوصة‬

‫‪12.‬‬ ‫اضاءات الطوارئ موجودة ومفحوصة‬

‫‪13.‬‬ ‫اسطوانات الغاز مثبتة بسالل بشكل جيد‬

‫‪14.‬‬ ‫يوجد نظام نداء في حمامات المرضى‬

‫‪15.‬‬ ‫يمكن فتح باب حمامات المرضى من الخارج‬

‫‪16.‬‬ ‫الثالجات مصنفة بالصق (لألدوية ‪ ،‬االطعمة)‬

‫‪17.‬‬ ‫ملف المواد الكيماوية كامل ومحدث لغاية تاريخه‬

‫‪18.‬‬ ‫تم عنونة ووضع الصق على جميع المواد الكيماوية في القسم‬

‫‪19.‬‬ ‫ادوات احتواء االنسكاب الكيماوي والحيوي موجودة وصالحة لالستخدام‬

‫‪20.‬‬ ‫دش الغسيل وغسيل العيون مفحوصة وتعمل‪ G‬بشكل جيد والطريق اليها سالك وامن وال يوجد عوائق‬

‫‪21.‬‬ ‫االجهزة الطبية مفحوصة وتعمل بشكل جيد والصق الفصح موجود‬

‫‪22.‬‬ ‫االجهزة االخرى ومحابس الغازات بحالة جيدة‬

‫‪23.‬‬ ‫يوجد معدات وقاية شخصية مناسبة وادوات مناسبة وغير تالفة‬
 ‫‪24.‬‬ ‫علبة االسعاف االولي وبطانية الحريق ومصباح احتياطي موجدة‬

‫‪25.‬‬ ‫لوحة االخالء في حال الطوارئ موجودة في القسم‬

‫‪26.‬‬ ‫يستطيع الموظفين شرح عملية استخدام الطفاية‬

‫‪27.‬‬ ‫يستطيع الموظفين شرح واجباتهم في حال االخالء والطوارئ‬

‫‪28‬‬

‫‪Other Comments:‬‬

‫المالحظات‬ ‫الموقع‬ ‫االهمية‬ ‫المسؤولية‬

‫‪#‬‬
‫‪Comments‬‬ ‫‪Location‬‬ ‫‪Priority‬‬ ‫‪Responsible‬‬

‫‪1‬‬

‫‪2‬‬

‫‪3‬‬

‫‪4‬‬

‫‪5‬‬

‫‪6‬‬

‫‪Surveyor(s) signature:‬‬

‫‪ENVIRONMENTAL / FACILITY ROUND FORM‬‬

‫‪Floor & Department:‬‬ ‫‪Date:‬‬

Head /supervisor:
1.0 Electrical

Tool Yes No NA Remarks

1.1 Patient care equipment inspection tag
outdated
1.2 Non-patient care equipment inspection tag
is outdated
1.3 Electrical boxes missing or damaged
1.4 Extension cords used as permanent wiring
1.5 Equipment located poorly
1.6 Cords located near a water source
1.7 Exposed wires
1.8 Power cords need to be rerouted away from
sink, water or chemicals
1.9 Broken equipment not properly tagged or
labeled
1.10 Critical equipment not plugged into red
outlets
2.0 Housekeeping
2.1 Area not clean
2.2 cleaning room doors are propped open
2.3 No ID
2.4 Housekeeping carts need repair
2.5 Area not orderly
2.6 Refrigerator needs to be cleaned
2.7 Improper storage on housekeeping cart
2.8 Improper storage of chemicals
2.9 Improper storage in janitors’ closet
2.10 Keys left in janitors closet
2.11 Dirty items
2.12 Items not clean
3.0 Fire Hazards
3.1 Fire exits obstructed
3.2 Fire extinguisher inspection tag outdated
3.3 Pull stations obstructed
3.4 Obstructed stairwells
3.5 Electrical boxes obstructed
3.6 Storage within 18 inches of the ceiling
3.7 Combustibles near a heat source
3.8 Aisles and passage ways obstructed
3.9 Fire extinguishers obstructed, missing or mounted too high
3.10 Doors propped, wedged, taped or tied open
3.11 Items located in front of/on top of flammable cabinet
3.12 Excessive amounts of combustibles stored
3.13 Heat producing equipment located poorly
3.14 Exit signs missing/obstructed
3.15 Inadequate storage of items on the floor
3.16 Fire alarm detection impaired
3.17 Exit sign not functioning properly
3.18 Items stored in fire hose cabinet
3.19 Fire extinguisher obstructed
3.20 Decorations not meeting applicable standards
3.21 Obstruction of fire/smoke door
3.22 Space heater found
3.23 Candles found
3.24 Fire doors not closing properly
3.25 Paint covering door rating tag
3.26 Glazing in door damaged
3.27 Holes found in door/door frame
3.28 Vertical penetrations
4.0 Engineering /Maintenance Controls
4.1 Med rooms/cabinets not locked
4.2 Exhaust hood needs cleaning
4.3 Sink/Counter top damage
4.4 Wall damage/painting needed
4.5 Door mesh not bolted to floor or ceiling
4.6 Items not properly installed
4.7 Floor covering in unsafe condition
4.8 Ceiling tiles missing or need repair
4.9 Doors in need of repair
4.10 Flammable cabinet needs repair
4.11 Holes in walls, floor or ceiling
4.12 Shelves/bracketing needs repair
4.13 Broken/cracked windows
4.14 Items need to be replaced
4.15 Lighting not functional/needs to be repaired or
replaced
5.0 General Safety
5.1 Compressed gas cylinders unidentified and/or
improperly stored
5.2 Equipment not properly functioning/guarded
5.3 Unsafe storage of items
5.4 Smoking related materials found
5.5 Improper storage under the sink
5.6 Personal items stored improperly
5.7 Chemicals not labeled
5.8 Chemicals stored on the floor
5.9 Open chemicals
5.10 Department does not have up-to-date chemical
inventory
5.11 Un-notified chemicals found
6.0 Trips and fall
6.1 Cords present tripping hazards
6.2 Supplies/equipment stored improperly
7.0 Personal Protective Equipment
7.1 PPE missing/improperly used or stored
7.2 “PPE Located Here” signs are missing
8.0 Hazardous medical waste
8.1 Biohazard waste improperly disposed
8.2 Waste malsegregation
8.3 Improper use of a biohazard bag
8.4 Biohazard waste container broken/needs
repaired
8.5 Red bag waste improperly stored
8.6 Sharps container needs to be installed
8.7 Unstable sharps containers
8.8 Trash can need to be replaced
8.9 Sharps container full
9.0 Signs and Labels
9.1 Labels used improperly/missing/coming loose
9.2 Secondary containers not properly labeled
9.3 Proper safety signs missing
9.4 Flammable cabinet not properly labeled
9.5 Evacuation routes posted incorrectly/missing
10.0Construction
10.1 Exits obstructed or not inspected daily
10.2 Temporary construction areas not smoke tight &
not built of non-combustible material
10.3 Additional firefighting equipment not available
10.4 Storage has not been reduced
10.5 Training in alternate fire safety not performed
10.6 Safety orientation for contractors not performed
10.7 Wires not capped/exposed/dangerously
located
10.8 “No smoking” signs posted
11.0 Flammables
11.1 Flammables not labeled/labeled incorrectly
11.2 Flammables stored improperly
11.3 Chemicals not separated by hazard type
11.4 Appropriate spill kits not present
11.5 Fume hoods have not been tested for face
velocity within 12 months
11.6 Velocity of fume hoods is not >0.3m per
minute
11.7 CO2 extinguishers not present
11.8 Broken glass containers full/not present
12.0 Public Safety
12.1 Keys found in doors
12.2 Chemical room unsecured
12.3 Biohazard waste open /not secure
12.4 Medication room open /not secure
13.0 Clinical Areas
13.1 Medication carts not properly working
13.2 Emergency medications not secured
13.3 Crush carts not properly logged
13.4 Narcotics not controlled at all times
13.5 Patient information not secured
14.0 Environmental Sensitive Areas
14.1 Safety rails need covering
14.2 Objects can be used as weapons
14.3 Breakaway hardware needed
14.4 Plastic draw on curtains need to be removed
14.5 Non-glass partitions needed
14.6 Vents need to be covered
14.7 Hinges present hazard
14.8 Engineering controls needed
14.9 Tamper-proof screws needed
14.1 Electrical outlets need to be covered
0
14.1 Sharps edges present
1
14.1 Other
2
15.0 Other/Miscellaneous

16.0 Notes/ required action, responsible person and Follow up

Note / observation Action needed Responsible Time Follow up
person frame
Unit supervisor________________________________________________ safety officer
________________________________________