Hand Hygiene

*****Sinks and soap located in each exam/procedure/lab/medication area*****

Health care provided lotion available and not expired

Alcohol based hand sanitizer available/not expired

Staff that provide patient care, handle equipment or medical supplies do not have nails with polish that is chipped or peeling. No artificial nails including nails with shellac and gel, extenders, and/or nail decals or natural nails with tips longer than 1/4 inch.

Personal Protective Equipment

*****PPE available for all staff (gloves, gowns, masks, safety eyewear)*****

Biological readiness and training completed twice per year (entered into Sanford Learn)


Sharps Safety Exemption for completed for all sharps in clinic without a safety device

Sharps disposal available where needed

Sharps disposal containers locked and secured

*****Sharps container emptied when contents reach the "fill' line (3/4 full)*****

Work Area Restrictions

Covered beverages and food are only in non-clinical areas or breakrooms

Refrigerator/Freezer Temperature Monitoring: Medications/Vaccines and Patient Food/Drink

Medications are stored away from the walls, floor and vents and not in the crisper drawers or door of the storage unit

Therapeutic ingestables (Pedialyte, Glucola) are stored below medications and/or vaccines

Temperature log is filled out appropriately with no out of range temperatures noted

*****Action documented in the event of a temperature failure*****

Separate refrigerators for food, specimens and medication

Appropriate refrigerator being used for vaccine storage

Correct thermometer is being used to monitor vaccines

Thermometer's calibration is up to date. Certificate on file

Min/Max temperature is logged daily according to state VFC policies

Emergency plan is readily available and up to date according to state VFC policies

Appropriate packing materials available to safely transport vaccines if needed

Freezer is defrosted on a routine basis

Ice machine is cleaned on a routine basis

Medical Equipment

*****All equipment is cleaned according to manufacturer's instructions*****
~Elephant Ear Washer
~Metal Ear Tips and Syringes
~Cryo tips/cryo prob
~Cautery tips
~Hyfrecator 2000 (using sheaths)
~Peak flow meters
~Tonometer tips
~Pap lights
~Inspiration Elite
~Nail Clippers (medical grade)

*****Equipment appears to be clean and is not visibly contaminated*****

*****Equipment is being cleaned daily and when visibly soiled:*****
~Blood pressure cuffs
~Keyboards in exam rooms

Scissors in exam rooms/procedures rooms are clean

Process in place for scissors used to cut clean bandages

Reagents are dated when opened

Suction machine is wiped down in between use, canister and tubing is single patient use

Kick bucket changed after each use

Privacy curtains are cleaned annually and as needed.

Medication/Supply Storage

*****Single use items are only used for one patient*****

Medications are properly labeled

Bottles of sterile water/saline dated when opened and discarded at the end of the day

Sterile versus non-sterile ultrasound gel
~bottle vs bulk

No expired supplies/medications (process for checking expiration dates on a regular basis)

Sterile supplies stored enclosed

Clean supplies stored in a clean area

Sterile supplies stored 8-10" above the floor, 5 inches from the ceiling, unless near a sprinkler head (no supplies 18 inches vertically from a sprinkler head--safety code so that sprinkler can function)

Storage bins for medical supplies are cleaned on a routine basis

Corrugated cardboard boxes used appropriately for medical supply storage

No supplies or boxes stored on the floor

Nothing stored underneath the sink without an Infection Prevention consultation

Ophthalmology--Competency checklist completed for eye medications

Safe Injection Practices

Medications are not prepared within 3 feet of a sink or a splash guard is mounted beside the sink

Multi-dose vials dated with outdate (28 days)

*****Single dose vials are used within one hour of opening, on only on patient, and discarded. Also, no needles on pre drawn syringes stored in fridge unless used within one hour.*****

Staff swab off the top of the vial before withdrawing medication.

*****Staff use a new needle and syringe if entering a vial more than once.*****

Staff do not pool leftover contents of vial with other single dose vials

*****Multi-dose vials are not brought into patient care areas/immediate treatment areas. If vial is in a patient care area, it is to be discarded after use.*****

The smallest vial available is used

Staff verbalize how to report unsafe practices, near misses, adverse events and errors


Exam/procedure rooms cleaned between patients and process identified in determining the room is clean

Separation of clean and dirty is clearly defined

Environment uncluttered, surface kept clear to allow for cleaning

No tears in vinyl furniture

Surfaces free of blood, dust, stains, cracks, no bugs in lights

Ceiling tiles intact and free of stains

Air vents are free of dust

Caulking around sink is intact

Cleaning Services established for clinic per contract. Communication log in place.

Waiting Rooms

Cover your Cough/Influenza signage and supplies available in waiting room

Toys cleaned per policy

Reading books that are unable to be cleaned are not in exam rooms/waiting rooms


Appropriate sani-wipes are available for cleaning

All disinfectant containers are labeled
Exp (30 days)

All reusable disinfectant containers are cleaned according to policy

Dirty Utility Room

Instrument cleaning process established and following manufacturer recommendations

All instruments are pre-cleaned using an enzymatic cleaner

Instruments being sent for sterilization are kept moist and transported in a covered container marked biohazard

Regulated medical waste containers available as needed (red, yellow, black)

No clean equipment and/or supplies are stored in dirty utility room


Clean and dirty are separated

Clean linen covered or stored in dedicated linen room and is stored separate from supplies

Hampers-dirty linen transported to a dirty utility room

No linen is stored on the floor

Steam Sterilization/Tabletop Steam Autoclaves

*****Steam sterilizer tested with a biological indicator test pack and read with controls per manufacturer instructions and is documented*****

*****Established procedure for if there is a positive spore report, positive growth or incomplete change on a chemical indicator*****

Clean and dirty work stations are readily identifiable

Instruments are sprayed with enzymatic cleaner and all visible bio burden is removed prior to placing in cleaner

*****Sterilization is completed according to policy/manufacturer's instructions*****

*****Steam Sterilizer is cleaned according to manufacturer's cleaning instructions and has the recommended routine maintenance*****

High Level Disinfection

All staff that perform HLD have been checked off on an annual competency

*****Proper PPE available and worn*****

Test strips are appropriately dated and not outdated

*****HLD completed according to policy/manufacturer's instructions*****

Log kept and consistently filled out

Labeled, covered container with expiration date on it

*****HLD solution is changed according to manufacturer recommendations*****

*****Room flows from dirty to clean and staff do not cross contaminate*****

Staff are able to articulate where eyewash station is and how to find SDS

Staff Education

What PPE is available for staff to use?

What is an example of when to wear a mask or gown/gloves?

How do your triage patients with possible communicable diseases?

What illnesses or diseases need to be reported to Infection Prevention when either suspected and/or positive? How do you report to Infection Prevention?

How do you know medical supplies or instruments are sterile? What would be a reason you would not use it?

Which medical devices are labeled as single-use, non-reusable, or disposable?

Define a sterile field.

What is the process for how to clean up a blood/body substance spill?

How do you report an exposure?

What are the contact times for the disinfectants used in your clinic?

What are some examples of when you would use bleach sipes to disinfect an exam room?

Describe the difference between a clean process and a dirty process. Give an example of when you use this in your daily practice.

Define cross contamination.

What is your process for transporting specimens and/or dirty equipment?

Blood pressure cuffs cleaned at least daily?

Thermometer cleaned daily and when visibly soiled?

Otoscope and ophthalmoscope cleaned at least daily?

Stethoscopes cleaned daily and when visibly soiled?

What do you currently do to monitor hand hygiene?

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.