University of Connecticut Health Center

John Dempsey Hospital

Emergency Equipment Checklist

The following items will be checked daily. Any equipment that is not found or not functioning will be
replaced immediately. Please sign after the appropriate date upon completing your dept/unit daily
emergency equipment check.

Emergency Cart:

Defibrillator:

Code Cart lock intact, check expiration date (cart outdate

Paper is loaded, extra roll available.
Visually check power cord, patient cables, and paddles for
corresponds to first med outdate)
wear, insulation nicks, broken wires or damage
Backboard - present
Check that device is plugged in and AC Mains light is on.
Sharps Container intact, not more than full
Check that hands-off defib cable is attached and plugged into
O2 tank secured on or next to cart, level above 500 PSI
the test load.
Suction and Canister - connecting tubing and full suction setCheck the paper print-out to verify that the defibrillator
up present.
performed its daily self test and passed. If self test did not
Ambu bag/mask - on top
complete or pass, perform a manual test of the device.
Documentation Clipboard - check if present (one should be
visible through plexiglass of locked top compartment)
Clinical Engineering fully tests the defibrillator every 6 months,
* Electrodes minimum of 6
per manufacturer recommendation; All function tests done by
* Multifunction defibrillation/pacemaker pads present,
CE, including battery output, are performed on battery power.
check expiration date
* Defibrillation (gel conductive) pads - present, check
EKG Machine:
expiration date
Machine plugged in for charging
* Electrodes, defibrillation pads and multifunction defib/pacer Chest/Limb leads attached
pads may be kept with the defibrillator/pacemaker on a
EKG paper loaded/extra available
separate cart.
Other: (Additional items may be added per unit needs)

Department__________________MONTH ___________________ Year_______________

Staff signature and lock number
REQUIRED daily
Signature

Staff signature and lock number

REQUIRED daily

Lock #

Signature

Staff signature and lock number

REQUIRED daily

Lock #

Signature

1.

12.

23.

2.

13.

24.

3.

14.

25.

4.

15.

26.

5.

16.

27.

6.

17.

28.

7.

18.

29.

8.

19.

30.

9.

20.

31.

10.

21.

11.

22.

8/09, Revised 11/12

Lock #