Hand Hygiene/Glove Use Observation Tool

• Unit

  Select

• Date of observation

  Date

• Staff being observed

  Select MD CRNA RN CNA RT XR EVS Med student-MS Nursing student-NS LAB Other

  • MD
  • CRNA
  • RN
  • CNA
  • RT
  • XR
  • EVS
  • Med student-MS
  • Nursing student-NS
  • LAB
  • Other

• Prepared by

• INSTRUCTIONS: Observe HH practice. Include a variety of disciplines. NOTE: Hand Hygiene refers to use of alcohol based hand rub or washing hands with soap and water for 20 seconds

HAND HYGIENE

• Before clean and aseptic procedures, including medication prep and prior to gown & glove for sterile procedures.

  Yes

  No

  N/A

• After contact with blood, body fluids, secretions or excretions, mucous membranes, non-intact skin.

  Yes

  No

  N/A

• After touching patient environment

  Yes

  No

  N/A

• After removing gloves or other PPE used for contact with body substances.

  Yes

  No

  N/A

• Before patient contact.

  Yes

  No

  N/A

• After patient contact upon exiting patient’s room.

  Yes

  No

  N/A

• Upon entering patient’s room before equipment only contact.

  Yes

  No

  N/A

• After equipment only contact upon exiting patient’s room.

  Yes

  No

  N/A

GLOVE USE

• When potential for hand contact with blood/body substance.

  Yes

  No

  N/A

• Gloves removed immediately after use and hand hygiene performed.

  Yes

  No

  N/A

SIGN OFF

• Observer Name and Signature

  Sign