Checklist template

Emergency cart and medical emergency readiness for clinics

A ready-to-use checklist with 120 items in 6 sections, covering Cart contents, Defibrillator, Oxygen, Medications, Drills, Records. Use it as-is in Bindy, or adapt it to your own standards in minutes.

  • 6 Sections
  • 120 Items
  • 98 Yes / No checks
  • 6 Scored ratings
  • 128 Points

Use this template How audits work

1. Cart contents 26 items

  1. The emergency cart or kit is kept in the location shown on the clinic floor plan Yes / No 1 pt
  2. Nothing is stored in front of or on top of the emergency cart Yes / No 1 pt
  3. The cart rolls freely and its brakes hold Yes / No 1 pt
  4. A contents list is attached to the cart, drawer by drawer Yes / No 1 pt
  5. The cart is closed with a numbered breakaway seal Yes / No 1 pt
  6. The seal number on the cart matches the last entry in the check log Yes / No 1 pt
  7. Seal number found on the cart Short text
  8. A bag-valve-mask is on the cart in each size named on the contents list Yes / No 1 pt
  9. Face masks for the bag-valve-mask are present in infant, child and adult sizes Yes / No 1 pt
  10. Oral airways are present in the full range of sizes on the contents list Yes / No 1 pt
  11. Nasal airways are present with lubricant Yes / No 1 pt
  12. The suction unit turns on and draws suction when tested Yes / No 1 pt
  13. Suction tubing and a rigid suction tip are attached or packed with the unit Yes / No 1 pt
  14. The battery of the portable suction unit is charged Yes / No 1 pt
  15. IV start supplies (catheters, tubing, tourniquet, saline) match the contents list Yes / No 1 pt
  16. A blood glucose meter with in-date test strips is on the cart Yes / No 1 pt
  17. A pulse oximeter on the cart powers on and gives a reading Yes / No 1 pt
  18. A manual blood pressure cuff is on the cart in adult and child sizes Yes / No 1 pt
  19. A stethoscope is on the cart Yes / No 1 pt
  20. A backboard or rigid surface for chest compressions is with the cart Yes / No 1 pt
  21. Gloves, masks and eye protection are on the cart Yes / No 1 pt
  22. The emergency algorithm cards on the cart are the current edition used by the company Yes / No 1 pt
  23. A length-based or weight-based pediatric dosing tape or chart is on the cart where children are seen Yes / No 1 pt
  24. No supply item checked on the cart was past its expiry date Yes / No 1 pt
  25. Expired supply items found on the cart Number
  26. Completeness of the emergency cart against its contents list Rating
    • Complete 5 pts
    • One or two items missing 3 pts
    • Several items missing 1 pt

2. Defibrillator 18 items

  1. The defibrillator is with the cart or mounted in a marked, unlocked cabinet Yes / No 1 pt
  2. A sign visible from the corridor marks the defibrillator location Yes / No 1 pt
  3. The status indicator shows the unit is ready for use Yes / No 1 pt
  4. Adult electrode pads are sealed and within their expiry date Yes / No 1 pt
  5. Expiry date of the adult electrode pads Date
  6. Pediatric pads or a pediatric key are present where children are seen Yes / No 1 pt
  7. A spare set of adult pads is stored with the unit Yes / No 1 pt
  8. The battery is within its install-by or expiry date Yes / No 1 pt
  9. A spare battery is available where the model requires one Yes / No 1 pt
  10. A rescue kit (razor, scissors, towel, pocket mask) is attached to the unit Yes / No 1 pt
  11. The daily or weekly readiness check is recorded according to the manufacturer's schedule Yes / No 1 pt
  12. The user test or self-test printout for the last check is on file where the model produces one Yes / No 1 pt
  13. The unit carries a current biomedical inspection sticker Yes / No 1 pt
  14. The unit is registered with the local emergency service or program where local regulation requires it Yes / No 1 pt
  15. Staff asked could find the defibrillator without help Yes / No 1 pt
  16. No recall or software update notice is outstanding for the model Yes / No 1 pt
  17. Readiness checks recorded in the last 30 days Number
  18. Defibrillator readiness Rating
    • Ready with in-date pads and battery 5 pts
    • Ready but checks not recorded 3 pts
    • Not ready for use 1 pt

3. Oxygen 19 items

  1. A portable oxygen cylinder is on or beside the emergency cart Yes / No 1 pt
  2. The cylinder gauge reads above the minimum pressure set by company policy Yes / No 1 pt
  3. Pressure of the portable oxygen cylinder (psi or kPa) Number
  4. A regulator with a flowmeter is attached to the cylinder Yes / No 1 pt
  5. The cylinder wrench or handwheel is attached to the cylinder Yes / No 1 pt
  6. The cylinder was opened during the visit and oxygen flowed Yes / No 1 pt
  7. A full spare cylinder is available at the clinic Yes / No 1 pt
  8. Full and empty cylinders are stored apart, with tags Yes / No 1 pt
  9. Cylinders are secured upright in a stand, cart or chain Yes / No 1 pt
  10. Stored cylinders are kept away from heat sources and electrical panels Yes / No 1 pt
  11. A "No smoking, oxygen in use" sign is posted where cylinders are stored Yes / No 1 pt
  12. Adult non-rebreather masks are stocked with the cylinder Yes / No 1 pt
  13. Pediatric oxygen masks are stocked where children are seen Yes / No 1 pt
  14. Nasal cannulas are stocked with the cylinder Yes / No 1 pt
  15. Oxygen tubing long enough to reach from the regulator to the bag-valve-mask is packed with the cylinder Yes / No 1 pt
  16. The cylinder is within its hydrostatic test date as stamped or labeled Yes / No 1 pt
  17. The oxygen supplier exchanges cylinders on request, with the last delivery record on file Yes / No 1 pt
  18. Staff asked could open the cylinder and set a flow rate Yes / No 1 pt
  19. Oxygen readiness Rating
    • Full cylinder, regulator and masks ready 5 pts
    • Usable but low or missing a spare 3 pts
    • Not usable 1 pt

4. Medications 21 items

  1. The emergency medications on the cart match the list approved by the medical director Yes / No 1 pt
  2. Epinephrine for anaphylaxis is present in the form on the approved list (auto-injector or ampoule with syringe) Yes / No 1 pt
  3. Epinephrine is present in a pediatric dose where children are seen Yes / No 1 pt
  4. An antihistamine for injection or oral use is present where the approved list includes it Yes / No 1 pt
  5. Aspirin for chewing is present where the approved list includes it Yes / No 1 pt
  6. Nitroglycerin spray or tablets are present where the approved list includes them Yes / No 1 pt
  7. A fast-acting bronchodilator with a spacer or nebulizer set is present where the approved list includes it Yes / No 1 pt
  8. Oral glucose is present where the approved list includes it Yes / No 1 pt
  9. Injectable glucose or glucagon is present where the approved list includes it Yes / No 1 pt
  10. Naloxone is present where the approved list includes it Yes / No 1 pt
  11. A medication to stop seizures is present where the approved list requires it Yes / No 1 pt
  12. No emergency medication on the cart is past its expiry date Yes / No 1 pt
  13. Earliest expiry date among the emergency medications Date
  14. Medications expiring within the next 60 days have been reordered Yes / No 1 pt
  15. A dosing reference card for the emergency medications is on the cart Yes / No 1 pt
  16. Syringes and needles in the sizes needed to give the medications are in the same drawer Yes / No 1 pt
  17. Emergency medications that require refrigeration are kept in a marked place in the medication refrigerator Yes / No 1 pt
  18. The medication drawer is sealed or locked between checks Yes / No 1 pt
  19. Standing orders or protocols for anaphylaxis are signed by the medical director Yes / No 1 pt
  20. Expired emergency medications found during the visit Number
  21. Emergency medication readiness Rating
    • All present and in date 5 pts
    • Present with items near expiry not reordered 3 pts
    • Items missing or expired 1 pt

5. Drills 17 items

  1. A mock medical emergency drill was held within the interval set by company policy Yes / No 1 pt
  2. Date of the last mock emergency drill Date
  3. Scenario used in the last drill (for example anaphylaxis, cardiac arrest, seizure) Short text
  4. The last drill included bringing the cart and the defibrillator to the patient Yes / No 1 pt
  5. The last drill included the call to emergency services, simulated Yes / No 1 pt
  6. Time from the alert to the arrival of the cart at the patient in the last drill (seconds) Number
  7. Roles in an emergency (leader, airway, compressions, recorder, caller) are assigned for each shift Yes / No 1 pt
  8. A staff member is assigned to meet the ambulance crew at the entrance Yes / No 1 pt
  9. The clinic's street address and suite number are posted at the phones for the emergency call Yes / No 1 pt
  10. An internal alert (overhead page, code phrase or button) tells staff where the emergency is Yes / No 1 pt
  11. Reception staff asked know how to raise the alert for a collapse in the waiting room Yes / No 1 pt
  12. The ambulance stretcher route from the entrance to the exam rooms is clear Yes / No 1 pt
  13. A written debrief of the last drill lists what to improve Yes / No 1 pt
  14. Improvements from the last drill debrief have been carried out Yes / No 1 pt
  15. Drills are held at different times so that all shifts take part Yes / No 1 pt
  16. At least one drill in the last 12 months used a pediatric scenario where children are seen Yes / No 1 pt
  17. Performance in the last drill according to its debrief Rating
    • Smooth, roles clear 5 pts
    • Delays or confusion on some steps 3 pts
    • Major gaps or no drill held 1 pt

6. Records 19 items

  1. The emergency cart check log is completed at the frequency set by company policy Yes / No 1 pt
  2. The log for the last 3 months has no missed checks Yes / No 1 pt
  3. Date of the last full check of the cart contents Date
  4. Each check is signed or initialed by the person who performed it Yes / No 1 pt
  5. The cart is restocked and resealed on the day it is used Yes / No 1 pt
  6. Each real medical emergency in the last 12 months has an event record Yes / No 1 pt
  7. Medical emergencies recorded at the clinic in the last 12 months Number
  8. Event records are reviewed by the medical director Yes / No 1 pt
  9. All clinical staff hold a current basic life support certificate Yes / No 1 pt
  10. Providers hold the advanced life support certificate required by company policy Yes / No 1 pt
  11. Reception staff hold a current basic life support certificate where company policy requires it Yes / No 1 pt
  12. Staff whose life support certificate has expired Number
  13. A tracking list shows the expiry date of each staff member's certificate Yes / No 1 pt
  14. Attendance at drills is recorded by name Yes / No 1 pt
  15. Corrective actions from the previous emergency readiness review have been completed Yes / No 1 pt
  16. Name of the person responsible for the emergency cart Short text
  17. Name of the clinic manager Short text
  18. Overall readiness for a medical emergency Rating
    • Cart, defibrillator, oxygen and medications ready, with drills held 5 pts
    • Equipment ready, with gaps in checks, drills or certificates 3 pts
    • Equipment missing, expired or not working 1 pt
  19. Corrective actions required Comments

About this template

This checklist is part of the Bindy template library. Yes / No checks score 1 point when met; ratings score the points shown for each option. The overall score is the percentage of points earned, with N/A answers excluded. In Bindy you can add photos, assign corrective actions, require sign-off and compare results across sites.

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