Joint Commission Rapid Review Tips
Soiled Utility Rooms
 Do not use for "storage" of patient use/patient contact items
 De-clutter, a place for everything and everything in its place, or get rid of it
 Monitor room "turnover;" nothing should sit still in these rooms for more than 24 hours; the idea is
to get it removed/cleaned and back in service w/in 24 hrs.
 Check drawers, cubbies, and cabinets for stashed supplies (that probably should not be in a soiled
utility room in the first place) that get outdated
 Watch for unsecured (loose) O2 cylinders, store empty and full separately
 Glucometer/Other Waived Testing reagents are dated when opened and not expired
 Glucometer/Other Waived testing meter, case, and docking station is wiped down with Cavicide (or
similar) wipe between patients
 PPE is readily available and used when required
 Make sure the door into the room latches when closing
 No staff food in these areas
Clean Supply Rooms
 Cardboard shipping boxes should be removed ASAP, nothing on the floors, 18” from sprinkler
 De-clutter, a place for everything and everything in its place, or get rid of it
 Check drawers, cubbies, and cabinets for stashed supplies that get outdated
 Check that PM (Preventive Maintenance) sticker on medical equip are not outdated
 Watch for unsecured (loose) O2 cylinders, max of 12 full, store empty and full separately
 Make sure the door into the room latches when closing
 No staff food in these areas
Clean Equipment Rooms
 De-clutter, a place for everything and everything in its place, or get rid of it
 Check that PM sticker on medical equipment is not outdated
 Check drawers, cubbies, and cabinets for stashed supplies that get outdated
 Watch for unsecured (loose) O2 cylinders, store empty and full separately
 Make sure the door into the room latches when closing
 No staff food in these areas
Medication Rooms
 Access medication for one patient at a time
 Understand processes for safe use of Look-Alike/Sound Alike medications
 Understand processes for safe use of High Alert medications
 Bar coding or confirm 5 R’s at time of med administration
106731381Feb-16 Patton Healthcare Consulting  www.PattonHC.com Page 1
of 3


No staff food in these areas
Are medication drawers in patient room/outside patient room locked after each access?
Blanket Warmers
 Do not co-mingle blankets and irrigation/IV fluids in the same warmer compartment
 Do not overload/fill too full with blankets – FIRE HAZARD
 Rotate blanket stock to avoid blanket becoming brittle and a FIRE HAZARD
 Blanket warmer thermostats may be set up to the maximum, 130 degrees F.
 No temperature monitoring/log necessary if supported by a written risk assessment
 Unfold blankets prior to being placed on patient (creased areas may be warmer than flat areas)
Fluid Warmer (UPPER CABINET IN APPROVED LOCATIONS ONLY)
 Irrigation and IV fluid warming only in areas that have received permission from pharmacy
 Do not co-mingle blankets and irrigation/IV fluids in the same warmer compartment
 Fluid warmers set no higher than 100 degrees F. (or per manufacturer)
 When stocking the warmer add a label to all Irrigation and IV fluid bottles/bags that includes the
EXPIRATION/BEYOND USE DATE that is 14 days from the day the item is placed in the warmer.
 Rotate stock to avoid outdates
 Monitor and log fluid warmer unit temperatures
Pantry (patient use) Refrigerators and Freezers
 DAILY temperature monitoring logs are the responsibility of (insert title)
 Inventory rotation is the responsibility of Nutrition Services
 Refrigerator /freezer logs must be up-to-date, CORRECTIVE ACTIONS ARE NOTED
 If using a min/max thermometer to monitor PERISHABLE ITEMS over a weekend when closed,
record the min/max temp reached over the weekend first thing Monday morning
 NO STAFF FOOD OR BEVERAGE IS PERMITTED IN THE PATIENT REFRIGERATOR OR FREEZER
 ALL PATIENT FOOD BROUGHT FROM HOME REQUIRES PATIENT LABEL AND DATE/TIME OF
PLACEMENT IN THE REFRIGERATOR; EXPIRATION AND DISPOSAL IS WITHIN 24 HOURS.
Housekeeping Closets
 No staff food in these areas
 Know how to access MSDS sheets for all chemicals
 Secure the closet when not occupied
Hallway Clutter
 Every item in a egress (fire exit) corridor must be on wheels and "in use," meaning, touched or
moved once every 30 minutes
 (Exceptions: carts/equipment stored in recessed alcoves, isolation carts, code cart, waiver items.)
 Do not park (even temporarily) wheeled equipment or carts inside the swing path of a magnetically
held-open fire door
106731381Feb-16 Patton Healthcare Consulting  www.PattonHC.com Page 2
of 3


Do not block fire extinguisher cabinets, medical gas cabinets, electrical breaker panel box
No wood wedges or other “props” are propping open doors
Code Carts
 Make sure to do cart checks daily and complete the log!
 A manual check of the defibrillator is done (insert frequency)
 If the unit is closed for the day, mark the log “CLOSED”
 If called in to do a case on a day the department is closed, the cart should be checked prior to the
start of the case
 Ensure that defibrillators and suction machines are plugged in at all times. If not routinely stored in
an area with a red outlet, move the cart to a red outlet whenever the hospital is operating on
emergency generator power
Fire Safety
 Review your unit fire response plan, be ready to speak to roles and
responsibilities/RACE/PASS/Evacuation Plan
 Understand policy on oxygen shut-off in the event of fire on the unit
 Know the location of fire extinguishers, pull stations, and evacuation route
Nurses/Staff Work Stations



Keep confidential patient information out of view and out of earshot
Challenge unauthorized individuals who appear to be looking for patient information
No staff food or drinks in the public nurses/staff work areas
Last Not Least – Hand Hygiene



Squirt and rub in/squirt and rub out
Use proper hand hygiene prior to donning gloves, after removing gloves, (and before re-donning
gloves)
Use soap & water when caring for C-Diff patients (alcohol is ineffective with spores)
106731381Feb-16 Patton Healthcare Consulting  www.PattonHC.com Page 3
of 3