SYRINGE & LINE LABELING — COMPLIANCE SPOT CHECK
Hospital: ________________________ | Dept Anesthesia	Form Code: F-25 | Version: ___ | Effective: ___ | PAGE 1 of 1

SECTION 1 — AUDIT DETAILS
Date/Time: ___________________________________ Auditor name: _________________________________	Area:   ☐ OR    ☐ NORA    ☐ PACU Room/Location: _______________________________ Shift:   ☐ AM    ☐ PM    ☐ Night

SECTION 2 — SYRINGE LABELING
Total syringes observed on anesthesia work surface: Unlabeled syringes observed: Any syringe with missing concentration/strength:	______________ ______________ ______________
Corrective action taken immediately: ☐ Yes      ☐ No	Compliance: ☐ Pass     ☐ Fail
Notes: _________________________________________________________________________________________________

SECTION 3 — LINE LABELING / LINE TRACE
IV infusion lines labeled near pump: Lines labeled near patient connection: High-risk lines segregated/identified (e.g., vasopressors/epidural): Line trace performed before infusion start (observed):	☐ Yes    ☐ No ☐ Yes    ☐ No ☐ Yes    ☐ No    ☐ N/A ☐ Yes    ☐ No    ☐ N/A
Overall Line Safety Compliance:      ☐ Pass          ☐ Fail

SECTION 4 — FINDINGS & ACTION

Main issue category: ☐ Unlabeled syringe    ☐ Wrong label    ☐ Missing concentration    ☐ Unlabeled line    ☐ Other: ______________ Immediate feedback given to: ☐ Anesthesia    ☐ Nursing    ☐ Both Action plan / education needed: ________________________________________________________________________________________________________________

SECTION 5 — SIGN-OFF
Auditor signature: ________________________________________	Area lead notified:   ☐ Yes    ☐ No Name: ____________________________________