Hand Hygiene - 5 Moments Observation - Infection Control

• Hospital Department

• Conducted on

  Date

• Prepared by

• Location
  Address

• Staff Interviewed Name, Title, Department:

Infection Control - Hand Hygiene - 5 Moments Observation

• Is the patient on isolation precautions?

  Yes

  No

Non-Isolation Patient

• Did staff member perform hand hygiene when entering the patient room/before patient contact? (moment 1)

  Yes

  No

  N/A

• Coached?

  YES

  NO

• Did staff member create or use a clean surface to place patient care items prior to use on the patient?

  Yes

  No

  N/A

• Coached?

  YES

  NO

• Did staff member perform hand hygiene after touching unclean inanimate objects or themselves before approaching the patient? (moment 5)

  Yes

  No

  N/A

• Coached?

  YES

  NO

• Did staff member perform hand hygiene before performing a clean and/or aseptic procedure? (ex. medication pass, dressing change, etc) (moment 2)<br>See Sterile technique question at the bottom.

  Yes

  No

  N/A

• Coached?

  YES

  NO

• Did staff member clean their hands in between providing ‘dirty’ and ‘clean’ patient care? (moment 3)

  Yes

  No

  N/A

• Coached?

  YES

  NO

• If any items became contaminated did the staff member discard or clean the item as appropriate? (ex. items falls on floor or dirty surface)

  Yes

  No

  N/A

• Coached?

  YES

  NO

• Were observed glove changes done correctly? (hand hygiene before and between glove changes)

  Yes

  No

  N/A

• Coached?

  YES

  NO

• Did staff member clean reusable equipment prior to storage or use on the next patient? (ex. glucometer, pulse oximetry, vital signs machine, etc.)

  Yes

  No

  N/A

• Coached?

  YES

  NO

• Did staff member perform hand hygiene upon exiting the patient room? (moment 4)

  Yes

  No

  N/A

• Coached?

  YES

  NO

Isolation Patient

• Upon entering the patient’s room, did staff member perform hand hygiene and apply the appropriate PPE correctly for the level of isolation? (moment 1)

  Yes

  No

  N/A

• Coached?

  YES

  NO

• Did staff member create or use a clean surface to place patient care items prior to use on the patient?

  Yes

  No

  N/A

• Coached?

  YES

  NO

• Did staff member perform hand hygiene after touching unclean inanimate objects or themselves before approaching the patient? (moment 5)

  Yes

  No

  N/A

• Coached?

  YES

  NO

• Did staff member perform hand hygiene before performing a clean and/or aseptic procedure? (ex. medication pass, dressing change, etc) (moment 2)<br>See Sterile technique question at the bottom.

  Yes

  No

  N/A

• Coached?

  YES

  NO

• Did staff member clean their hands in between providing ‘dirty’ and ‘clean’ patient care? (moment 3)

  Yes

  No

  N/A

• Coached?

  YES

  NO

• If any items became contaminated did the staff member discard or clean the item as appropriate? (ex. items falls on floor or dirty surface)

  Yes

  No

  N/A

• Coached?

  YES

  NO

• Were observed glove changes done correctly? (hand hygiene before and between glove changes)

  Yes

  No

  N/A

• Coached?

  YES

  NO

• Did staff member clean reusable equipment prior to storage or use on the next patient? (ex. glucometer, pulse oximetry, vital signs machine, etc.)

  Yes

  No

  N/A

• Coached?

  YES

  NO

• Did staff member perform hand hygiene upon exiting the patient room? (moment 4)

  Yes

  No

  N/A

• Coached?

  YES

  NO

• Ask the assigned nurse/caregiver if there is documentation in the chart that the patient/family received education on Isolation Practices and if the patient/family refused education.

  Yes

  No

  N/A

• Coached?

  YES

  NO

• Sterile technique: Observe a staff member performing a sterile technique; did the staff member appropriately maintain sterile technique? (Ex. Did not touch non-sterile objects during procedure without removing gloves, glove changes with hand hygiene in between)

  YES

  NO

Completion

• What sterile technique procedure did you observe?

• Comments/Coaching/Equipment observed:

• Observer Name & Signature:

  Sign