Infection Control - Hand Hygiene - 5 Moments Observations

Staff Interviewed Name, Title, Department:

Infection Control - Hand Hygiene - 5 Moments Observation

Is the patient on isolation precautions?

Non-Isolation Patient

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

Coached?

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

Coached?

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

Coached?

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

Coached?

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

Coached?

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

Coached?

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

Coached?

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

Coached?

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

Coached?

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)

Coached?

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

Coached?

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

Coached?

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

Coached?

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

Coached?

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

Coached?

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

Coached?

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

Coached?

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

Coached?

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.

Coached?

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)

Completion

What sterile technique procedure did you observe?

Comments/Coaching/Equipment observed:

Observer Name & Signature:
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.