Healthcare Patient Safety Protocol Assessment
Systematically assess compliance with patient safety protocols in healthcare settings.
Facility Name
*
Department/Unit
*
Assessor Full Name
*
First Name
Last Name
Assessor Email Address
*
example@example.com
Assessment Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hand Hygiene Compliance
*
Rows
Always
Usually
Sometimes
Never
Staff wash hands before/after patient contact
1
2
3
4
Hand sanitizer available in all patient care areas
5
6
7
8
Medication Safety Practices
*
Rows
Excellent
Good
Needs Improvement
Not Observed
Medications labeled correctly
9
10
11
12
Double-checks performed before administration
13
14
15
16
Infection Control Measures
*
Appropriate use of personal protective equipment (PPE)
Regular cleaning of patient areas
Isolation procedures followed when required
Other
Incident Reporting Process
*
Clear and accessible to all staff
Available but not well understood
Unclear or not available
Other
Staff Training on Safety Protocols
*
1
2
3
4
5
Please provide any additional comments or observations
Submit Assessment
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