INTENSIVE CARE UNIT AUDIT CHECK LIST

S.No DISPLAY Status Responsibility Remarks

1 5 moments of Hand Hygiene Available
2 Hand wash Available
3 Hand rub Available
4 Needle stick Injury Protocol Available
5 Blood and Body fluids spill protocol Available
6 Mercury spill protocol display Not Available
7 Biomedical waste management display Available
8 Caution X ray signage for Radiation exposure Available
9 PM & Calibration for all the equipment stickers Not Available
10 Instruction /operator protocol displayed in the Machine Not Available
11 Emergency codes Not Available
12 Material Safety Data Sheets Display Not Available
13 Hazardous materials cupboard Available
14 Medication Cupboard Available
15 BLS protocol Displayed Available
16 ACLS protocol Displayed Available
17 Occupational hazards Not Available
18 MEWS score Available
19 LASA and high alert medication display Available
20 Fire Exit Available
21 Materials Holding area signages Not Available
22 Departmental signages Available
23 Intensive Care Unit Available
24 Entry Restricted Not Available
25 Please remove your footwear here Available
25 Visiting hours Available
26 ICU Cot Number Not Available
27 Fridge medications Available
28 Admission Criteria Available
29 Transfer Criteria Available
30 Discharge Criteria Available
31 ICU Protocols Not Available
32 Escalation Matrix Not Available
33 Complaint contact number-OT Waiting area Not Available
34 Fire exit Not Available
35 Department organogram display Not Available
IMPLEMENTATION

1 Safety of electrical plugs & Sockets-(Check for loosely tangling wires)

2 Any damaged items in the area which has potential for Injury.
3 Separate Slippers for wearing Available
4 Cap and mask availability Available
5 Availability of hand rub at the entrance Available
6 Availability of Hand rub inside the ICU Available
7 Hand rub stand in all cots Available
8 Availability of hand wash solution Available
9 Segregation of sound alike, look alike and high alert medications Available
10 Red dot in high alert medication ampoules Available
11 Narcotic Cupboard-Double lock Not Available
12 Mobile oxygen cylinder Available
13 Suction Apparattus Not Available
14 Crash Cart Available
15 Ward Inventory Available
16 RO water facility if dialysis facility available Available
17 Elbow or Knee action tap Available
18 Spill kit for Blood and body fluids Available
19 Spill kit for Mercury Available
20 Stretcher with safety belts Not Available
21 Wheel chair with safety belts Not Available
22 Linen trolley-Clean linen and Soiled linen separately Not Available
23 Needle cutter Not Available
24 Puncture proof container Available
25 Availability of Biomedical waste bins Available
26 Fridge Temperature monitor Not Available
27 High level disinfectants
28 Employee health check up Available
29 Staff vaccination Available
30 Medication label Not Available
31 Eye Wash Not Available
32 Grab bars in patient rest rooms Not Available
33 Adequate side rails Available
34 Sample collection box Not Available
35 Isolation Room Available
36 Lead apron Available
37 Lead Apron leak proof test Not Available
38 TLD Badge Not Available
39 Hazardous materials are identified and stored separately under lock Not Available
and key
DOCUMENTATION
1 ICU Counselling form Available
2 ICU Nominal register Available
3 Quality indicators register Available
4 ICU Chart Available
5 Drug inventory replacement register Available
6 Narcotic request form Not Available
7 Narcotic stock Register Not Available
8 Narcotic usage and discard register Not Available
9 Transfer Register Not Available
10 ICU Consent form Not Available
11 High risk consent form Available
12 DIL form Available
13 Pain assessment and reassessment Available
14 Pediatric DNR form
15 Adult DNR Form Available
16 Fall risk assessment form Not Available
17 Consent for restraints Available
18 Physical restraint form Available
19 Chemical restraint form Available
20 Consent moderate sedation Not Available
21 Moderate sedation monitoring chart Not Available
22 Fridge medications list Available
23 Departmental Manual Not Available
24 Equipment Stock Register Available
25 HPE register Not Available
26 Communication Register Available
27 CSSD register Available
28 Indent register Available
29 Equipment Breakdown register Not Available
30 Equipment operating manual Not Available
31 Asset list of equipments Not Available
32 Preventive Maintenance plan Not Available
33 Equipment hiring form Not Available
34 Equipment rental form Not Available
35 Equipment demo form Not Available
36 Equipment condemnation form Not Available
37 Complaint Register Not Available
38 Referral form Not Available
39 LAMA form Available
40 HAI Surveillance Register Available
41 CAUTI Available
42 CLABSI Available
43 VAP Available
44 SSI Available
45 Bedsore Available
46 HAI Surveillance Bundle
47 CAUTI
48 CLABSI
49 VAP
50 SSI
51 Bedsore
52 HAI Surveillance Checklist
53 CAUTI
54 CLABSI
55 VAP
56 SSI
57 Bedsore
58 Transfer order form Available
59 CPR Register Not Available
60 Death Register Available
61 Temperature checklist for Refrigerator Available
62 Fumigation Record Available
63 List of sound alike, look alike and high alert medications list Available
64 Emergency trolley medicine, Intubation tray checklist Available
65 O2 Cylinder checklist Available
66 Suction apparattus checklist Not Available
67 Defibrillator checklist Available
68 Multiparamonitor checklist Not Available
69 Code blue report form Not Available
70 Medication error report form Not Available
71 Adverse drug event reporting form Not Available
72 Emergency drill reporting form Not Available
73 CSSD Recall Register Not Available
74 Medication Recall Register Not Available
75 Incident Reporting form Not Available
76 Safety checklist for procedures Not Available
77 Procedure form Available
78 Blood transfusion register Available
79 Blood request form Available
80 Blood transfusion monitoring chart Available
81 Post transfusion reaction reporting form Not Available
82 Needle stick injury reporting form-General Not Available
83 Post exposure reporting form-General Not Available
84 Hospital Formulary Not Available
85 Swab culture report Available
86 MSDS file Not Available
87 Water quality check report Not Available
88 Antibiotic policy Not Available
89 Housekeeping cleaning checklist Available
90 Biomedical waste collection checklist Not Available
91 Adequate staff available as per INC ratio
92 Patient Assignment register Not Available
93 Handing Over Register Available
94 End of life care checklist Not Available
95 Organ donation counselling form Not Available
96 Organ donation register Not Available
97 TLD badge report Not Available
98 Lead Apron leak proof test Not Available
 99 List of verbal order medications Not Available
100 Verbal order seal or form Not Available
101 Medication reconciliation form Not Available
102 Duty Roster Available
TRAINING
1 Departmental SOP & Policies
2 Emergency codes
3 Patients rights & Responsibilities
4 Employee rights & responsibilities
5 Occupational Hazards
6 Incident Reporting system
7 Hospital Vision, Mission & Values
8 HIC Practices
9 MEWS
10 BLS, ACLS
11 Patient Safety goals
12 Narcotic Policy
13 NABH OT Guidelines
14 HEPA Filter checking record
15 Radiation safety training
16 Sample collection training
17 Recall procedure
18 Fire safety