CATH LAB UNIT AUDIT CHECK LIST

S.No DISPLAY Status Remarks

1 5 moments of Hand Hygiene Yes
2 Hand wash Yes
3 Hand rub Yes
4 Needle stick Injury Protocol Yes
5 Blood and Body fluids spill protocol Yes
6 Mercury spill protocol display Yes
7 Biomedical waste management display Yes
8 Asset Label No
9 PM Label No
10 Calibration Label No
11 Instruction /operator protocol displayed in the Machine No
Phone number is not
12 Yes
Emergency codes available
13 Material Safety Data Sheets Display Yes
14 Hazardous materials cupboard No
15 Medication Cupboard Yes
16 Caution X ray signage Yes
17 List of procedures No
18 HIRA No
19 Cath Lab Scope of services display No
20 LASA and high alert medication display Yes
21 Fire Exit Yes
22 Materials Holding area signages No
23 Cath Lab-Department signage B/L Yes
24 Console room display No
25 Entry Restricted Yes
26 Please remove your footwear here Yes
27 AERB License display-Cath Lab Yes
28 AERB License display-RSO No
29 Radiation safety instructions display Yes
30 Bundle check criteria No
31 Refrigerator Medicines Display No
32 Department organogram display No
IMPLEMENTATION
Safety of electrical plugs & Sockets-(Check for loosely tangling
1 No
wires)
2 Availability of hand rub at the entrance Yes
3 Availability of Hand rub inside the Cath Lab Yes
4 Availability of hand wash solution Yes
5 Availability of PPE for staffs Yes
Segregation of sound alike, look alike and high alert
6 Yes
medications
7 Red dot in high alert medication ampoules No
8 Mobile oxygen cylinder Partially closed Available in CT OT only
9 Crash Cart Yes
10 Ward Inventory Yes
11 Elbow or Knee action tap Yes
12 Availability of sterile trays Yes
13 Spill kit for Blood and body fluids Yes
14 Spill kit for Mercury No
15 Needle cutter No
16 Puncture proof container Yes
17 Availability of Biomedical waste bins Yes
18 High level disinfectants Yes
19 Employee health check up Yes
20 Staff vaccination Yes
21 Hazardous materials are identified and stored separately under No
lock and key
22 Narcotic double lock cupboard Yes
23 Lead Apron Yes
Staff-6, Doctors-7 and
24 Yes
TLD badge Technician-2
25 Storage area for stents and wires Yes
26 Preliminary washing area Yes
27 Lead apron holding area Yes
28 Stretcher holding area Yes
29 Biomedical waste bins Yes
30 Medication cupboard Yes
31 Medication Label Yes
32 Temperature monitor for refrigerator Yes
33 Medical Gases pipeline colour coding No
34 Stretcher with safety belt Yes
DOCUMENTATION
1 Cath Lab Nominal register Yes
2 Cath Lab procedure form No
3 Procedure form No
4 Implant Register No
5 Scientific criteria-Implants No
6 Consent for diagnostic procedures Yes Tamil not available
7 Consent for therapeutic procedures Yes Tamil not available
8 Cath Lab equipment checklist No
9 Patient instructions pamphlets No
10 Safety checklist for procedures No
11 Medication stock register Yes
12 Consent for procedures Yes
13 Equipment Stock Register Yes
14 Communication Register No
15 CSSD register Yes
16 Indent register Yes HIMS
17 Equipment Breakdown register Yes HIMS
18 Equipment operating manual No
19 Asset list of equipments No
20 Preventive Maintenance plan No
21 Calibration plan No
22 QA report Yes
23 Complaint Register Yes HIMS
24 Referral form No
25 Refusal for treatment form No
26 Transfer order form Yes
27 Deep cleaning Record No
28 List of sound alike, look alike and high alert medications list Yes
29 Medicine checklist Yes
30 O2 Cylinder checklist Yes
31 CPR report form No
32 Medication error report form No
33 Adverse drug event reporting form No
34 Emergency drill reporting form No
35 Incident Reporting form No
36 Housekeeping cleaning checklist Yes
37 Biomedical waste collection checklist Yes
38 Transfer or discharge criteria No
39 Narcotic stock register No
40 Narcotic usage and discard register Yes
41 Lead apron leak proof test No
42 TLD badge report Yes
43 Cath Lab Manual No
44 Temperature checklist for refrigerator Yes
45 Annual safety return report No
46 Terminal end-air quality check report No
47 Culture Report-Monthly once Yes
48 Clinical Audit No
49 Duty Roster Yes HIMS
OTHERS

1 Water leak present in cath lab roof at the time of audit. Loaded
medicines stored in the fridge which is already date barred. 30
degree centigrade storage medicines stored inside the
refrigerator.
Responsibility
HIC Champion
HIC Champion
HIC Champion
HIC Champion
HIC Champion
HIC Champion
HIC Champion
FMS Champion
FMS Champion
FMS Champion
FMS Champion
FMS Champion
FMS Champion
FMS Champion
MOM Champion
FMS Champion
COP Champion
FMS Champion
COP Champion
MOM Champion
FMS Champion
COP Champion
FMS Champion
FMS Champion
FMS Champion
FMS Champion
ROM Champion
ROM Champion
AAC Champion
COP Champion
MOM Champion
HRM Champion

FMS Champion
HIC Champion
HIC Champion
HIC Champion
HIC Champion
MOM Champion
MOM Champion
FMS Champion
MOM Champion
MOM Champion
HIC Champion
HIC Champion
HIC Champion
HIC Champion
HIC Champion
HIC Champion
HIC Champion
HIC Champion
HRM Champion
HIC Champion
FMS Champion
MOM Champion
AAC Champion
AAC Champion
COP Champion
HIC Champion
AAC Champion
FMS Champion
HIC Champion
MOM Champion
MOM Champion
MOM Champion
FMS Champion
FMS Champion

COP Champion
COP Champion
COP Champion
MOM Champion
MOM Champion
COP Champion
COP Champion
FMS Champion
PRE Champion
COP Champion
MOM Champion
COP Champion
FMS Champion
PRE Champion
HIC Champion
FMS Champion
FMS Champion
FMS Champion
FMS Champion
FMS Champion
FMS Champion
FMS Champion
FMS Champion
AAC Champion
AAC Champion
AAC Champion
HIC Champion
MOM Champion
MOM Champion
FMS Champion
COP Champion
MOM Champion
MOM Champion
PSQ Champion
PSQ Champion
HIC Champion
HIC Champion
AAC Champion
MOM Champion
MOM Champion
AAC Champion
AAC Champion
COP Champion
MOM Champion
AAC Champion
FMS Champion
HIC Champion
PSQ Champion
HRM Champion