Title Page

  • Conducted on

  • Prepared by

  • Location

  • Modalities observed:

  • If other, specify:


Hand Hygiene

  • Alcohol based hand rub (ABHR) available

  • Soap and water available

  • Staff know when the use Soap versus ABHR

  • Performed before patient contact

  • Performed after patient contact

  • Other:

Transmission Based Precautions

  • Gloves readily available

  • Gowns readily available

  • Masks readily available

  • Eye protection available

  • Appropriate use of PPE demonstrated

  • Don PPE appropriately

  • Doff PPE appropriately

  • Universal masking

  • Respiratory etiquette signage in place

  • Standard precautions observed for all patients

  • Appropriate precautions implemented for indicated precautions (.e. enteric, neutropenic, airborne, droplet, etc.)

  • Process for potential/confirmed respiratory infectious disease

  • Staff can state what to do for accidental exposure to transmissible pathogens

  • Other:


  • Patient care surfaces disinfected between patients

  • Appropriate surface disinfectants are used

  • Wet times appropriate for disinfectant

  • Patient care area free of dust accumulation

  • Care areas free of clutter

  • Air vents free of dust accumulation

  • Clean rooms positively pressured

  • Soiled rooms negatively pressured

  • Aerosolizing procedures conducted in negative pressure room

  • Biohazardous waste is managed appropriately

  • Pharmaceutical waste is managed appropriately

  • Sharps disposal management appropriately

  • Battery disposal managed appropriately

  • Hazardous materials are managed appropriately

  • Mainstream trash is managed appropriately

  • Clean linens are covered

  • Biomedical Equipment has a current Preventive Maintenance (PM) Sticker date

  • Equipment is clean (free of dust and debris)

  • Other:

Point of Care Testing

  • There should be no evidence of grime, dirt, adhesive marks, or blood left on the device, case or supplies

  • Devices and cases are cleaned after every use

  • Reagents dated per manufacturer's instructions for use

  • Other:

Procedure Rooms / Instruments

  • Appropriately "restricted" or "semirestricted"

  • Traffic controlled during procedures

  • Temperature and humidity monitored & documented

  • Surgical attire, if required, managed appropriately

  • Appropriately turnedover between patients

  • Terminally cleaned/logged

  • Positively pressured (unless bronchoscopy or other aerosolizing procedure)

  • Instruments for reprocessing rinsed at point of use

  • Instruments for reprocessing kept moist with enzymatic spray until transported to SPD

  • Instruments for reprocessing transported in rigid, covered biohazardous labelled container

  • Sharps discarded prior to transport

  • Other:

HighLevel Disinfection

  • Instruments for HLD are processed initially at point of use

  • Instruments are transported for HLD appropriately

  • HLD quality controls are documented for the sterilants used

  • HLD lot numbers and indicators are documented (logged) as applicable

  • Bidirectional traceability documentation is present as applicable

  • After HLD, instruments are stored in a manner that protects their disinfection

  • Other:

Clean Storage

  • Temperature and humidity monitored & documented

  • Room is positively pressured

  • Pouched sterilized instruments are stored appropriately

  • Processed scopes (TEEs) are stored appropriately; and storage cabinet is free of dust and debris

  • Only clean items/equipment are stored in this area

  • The room is free of dust, dirt, grime, etc

  • Scopes are labeled with process date. Per hospital procedure, are reprocessed at least every 14 days

  • No expired supplies

  • Other:

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.