Information
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Audit Title
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Document No.
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
Summary of Survey
Employee Hand Hygiene Compliance
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Employees Monitored
1.0 Employee PPE
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Employee wearing appropriate PPE
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Employee wearing PPE appropriately
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Staff remove gloves before moving to the next task or patient
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Staff wear gloves for procedures that might involve contact with blood or body fluids?
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Staff wear gloves when handling potentially contaminated patient equipment?
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Eye wash station checked weekly. Have staff member demonstrate
2.0. Soiled Instruments
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Instrument carts are being received with the 'Dirty' sign on side of cart
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Soiled instruments are moist when they are received from other departments
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Instruments are received unhinged
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Instruments in the washer are not stacked
3.0 Single use devices, sterilization, HDL
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3.5. Items are pre-cleaned according to manufacturer's instructions or evidence based guidelines prior to sterilization?
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3.6. Medical devices and instruments are visually inspected for residual soil and re-cleaned as needed before packaging and sterilization.
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3.7. a chemical indicator is placed in each load.
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3.8. A biological indicator is performed at least weekly and with all implantable loads.
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3.9. Each load is monitored with mechanical indicators (e.g. time, temperature, pressure)
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3.10. Documentation for each piece of sterilization equipment is maintained and up to date and includes results from each load.
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3.11. Items are appropriately contained and handled during the sterilization process to assure sterility is not compromised prior to use.
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3.12. After sterilization, medical devices and instruments are stored in a designated clean area so sterility is not compromised.
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3.13. Sterile packages are inspected for integrity and compromised packages are reprocessed.
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3.14. Semi critical equipment is high-level disinfected or sterilized.
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3.15. Items are pre-cleaned according to manufacturer's instructions or evidence-based guidelines to high-level disinfection.
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3.16. High-level disinfection equipment is maintained according to manufacturer's instructions.
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3.17. Chemicals used for HDL are prepared according to manufacturer's instructions.
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3.18. chemicals used for HDL are tested for appropriate concentration according to manufacturer's instructions.
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3.19. Chemicals used for HDL are documented to have been prepared and replaced according to manufacturer's instructions.
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3.20. Instruments requiring HDL are disinfected for the appropriate length of time as specified by manufacturer's instructions or evidence based guidelines.
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3.21. Instruments requiring HDL are disinfected at the appropriate temperature according to manufacturer's instructions or evidence based guidelines.
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3.22. Items that undergo HLD are allowed to dry before use.
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3.23 Following HDL, items are stored in a designated clean area in a manner to prevent contamination.
4.0 Environmental Infection Control.
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4.1. Operating Rooms are cleaned and disinfected after each surgical or invasive procedure with EPA registered disinfectant.
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4.2. Operating rooms are terminally cleaned daily.
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4.3. High touch surfaces in patient care areas are cleaned and disinfected with an EPA registered disinfectant.
Additional Comments
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Additional Comments
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Surveyor's Signature
