Audit

Infection prevention and Control Checklist
Policy

Updated infection control policy and procedures is available in the department .

Staff aware about the policy and procedures and it is accessible for them.

Healthcare Personnel (HCP) receive job-specific training on infection prevention policies and procedures upon hire and at least annually .

Hand Hygiene

Hand hygiene supply is available .

HCP demonstrate appropriate techniques for hand washing and hand rubbing .

Visual alerts are available:
-    WHO 5 moments
-    How to Hand Rub (beside alcohol dispensers)
-    How to Hand Rub (beside alcohol dispensers)

PPE

Sufficient and appropriate PPE are available and readily accessible to HCP.

Staff use personal protective equipment appropriately.

Environmental disinfection

There is a cleaning schedule and is applied

Environmental surfaces is clean and is free from soil.

Housekeeping surfaces (e.g., floors, walls, and sinks) cleaned with MOH approved detergent/ disinfectant using double/ or triple bucket technique or scrubbing machines.

Housekeeping equipment is kept clean and dry after use.

There is one spill kit, at a minimum in the department.

Health care personnel demonstrate appropriate technique for management of blood and/or body fluids.

Appropriate PPE, e.g. gloves, masks, gowns and protective eyewear, worn by housekeepers during their routine activities.

Nurses are responsible for cleaning of all environmental surfaces in patient areas except floors, walls, ceiling and bathrooms.

Waste Management

All types of waste containers are available in sufficient number and placed in easily accessible sites and away from traffic.

Sharp items (e.g., needles, scalpel blades, broken metal instruments, and burs) are placed in an appropriate sharps container (puncture resistant, color-coded, and leak-proof).

Used needles are not manipulated or recapped and are promptly disposed into sharp containers.

Staff sticks to the approved policies of proper medical waste segregation ( no dangerous medical waste or sharps are observed outside specified containers)

Medical waste bags and sharp boxes are 3/4 filled.

Aseptic technique

The patient’s skin are disinfected with an appropriate antiseptic before injection or cannulation .

Proper fixation of the peripheral venous cannula with written date of insertion.

Preparation & dilution of drugs' vials is only done by ready-made sterile water ampoule.

Needles and syringes including prefilled syringes, vacutainer holders are used for only one patient.

All patient care supplies are brought to patient area when needed with no excess item in the area.

If Multi-dose vials must be used , should be dedicated for one patient (as possible as we can) and dated when they are first opened and discarded after 28 days unless the manufacturer specifies a different date for that opened vial.

The rubber self-sealed cap on a medication vial is disinfected with alcohol prior to piercing .

IV solution bottles are only accessed through the self-sealed rubber cap.

Multidose medication vials are accessed with a new needle and a new syringe, even when obtaining additional doses for the same patient.

No needles are kept inside the self-sealed rubber cap of IV solution bottle or Multidose vials.

Only sterile fluids used in nebulizers , humidifiers, or any aerosol generator.

Changing ventilation circuits only when visibly soiled or mechanically malfunctioning.

Only sterile fluids used in nebulizers or any aerosol generator, dispensing aerosol fluids aseptically.

Evacuation of urine bag is done in proper way using appropriate P.P.E.

All items in patient zone used for patient care only and any remaining items after patient discharge are considered contaminated even in their wrapping.

All used (contaminated ) reusable items sent to Central Processing Department (CPD) in proper way without any interference from the staff.

Separate clean area is available for preparing medications

Laundry

Contaminated linen is collected with minimum agitation in special color-coded and waterproof laundry bags .

Linen carts are covered and not overfilled.

Isolation

Contact isolation precautions are initiated for patients infected or colonized with multidrug-resistant organisms.

Patients with larger burns (>25% total body surface area) are placed in a single room, when applicable, as an additional precaution.

Storage area

Storage area should fulfill the following requirement:-

Clean and dry (temperature and humidity must be controlled)

Away from air vents and well ventilated

Storage shelves are 40 cm from the ceiling, 20 cm from the floor, and 5 cm from the outside wall.

Storage shelves made from easily cleanable material (not wood or Cardboard)

Sterile and clean items completely separated from personal items &foods and drinks .

Rotate supplies on a first-in-first-out basis so as to avoid the use of expired items.

Items not kept in original cardboard shipping boxes

Surveyor Signature
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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.