Infection Control Monitoring

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Previous Inspection

• Has the last inspection been reviewed?

• Details

Managers - Infection Control performed an inspection of your unit. Please review your survey and document your Plan of Correction next to each deficiency.

1.0 Hand Hygiene

• 1.1. Hand sanitizer is available and accessible for the patients and visitors in all waiting areas?

  Yes

  No

  N/A

• 1.2. Available liquid soap within all treatment rooms?

  Yes

  No

  N/A

• 1.3. Wall mounted paper towels available near each sink?

  Yes

  No

  N/A

• 1.4. Free from bar soaps?

  Yes

  No

  N/A

• 1.5. Posters in appropriate locations demonstrating good handwashing techniques?

  Yes

  No

  N/A

• 1.6. Clinical staff able to demonstrate good handwashing techniques?

  Yes

  No

  N/A

• 1.7. Staff able to apply 5 moments of hand hygiene?

  Yes

  No

  N/A

2.0. General Cleaning/Environment

• 2.1. Floors are cleaned with a disinfectant?

  Yes

  No

  N/A

• 2.2. Flat surfaces and OR lights are cleaned with a disinfectant solution?

  Yes

  No

  N/A

• 2.3. Special equipment is wiped with a damp cloth and returned to proper storage place?

  Yes

  No

  N/A

• 2.4. Linen/trash bags are closed and placed in appropriate area for disposal?

  Yes

  No

  N/A

• 2.5. Walls and doors are spot cleaned?

  Yes

  No

  N/A

• 2.6. Hallways and sub-sterile areas are mopped with disinfectant?

  Yes

  No

  N/A

• 2.7. Cabinets, autoclave and countertops are wiped with disinfectant?

  Yes

  No

  N/A

• 2.8. Patient care stations are kept clean and neat?

  Yes

  No

  N/A

• 2.9. Is OT cleaned according to policy?

  Yes

  No

  N/A

• 2.10. Are storage shelves clean?

  Yes

  No

  N/A

• 2.11.Is equipment properly cleaned and stored?

  Yes

  No

  N/A

• 2.12. Are sharp containers at appropriate levels?

  Yes

  No

  N/A

• 2.13. Staffs are aware not to bend, recap ore remove contaminated needle or sharps unless it is absolutely necessary?

  Yes

  No

  N/A

3.0 Staff Controls

• 3.1. All staff is free of respiratory infections and/or skin lesions?

  Yes

  No

  N/A

• 3.2. Good personal hygiene is observed?

  Yes

  No

  N/A

• 3.3. Scrub suits worn are cleaned by facility service; caps, shoe covers are worn when in department for non-dedicated shoes?

  Yes

  No

  N/A

• 3.4. Masks are worn correctly and changed in between cases?

  Yes

  No

  N/A

• 3.5. Clean lab coat worn over scrubs outside of the surgical area?

  Yes

  No

  N/A

• 3.6. Scrub suits and shoe covers are changed when wet/soiled?

  Safe

  At Risk

  N/A

• 3.7. Sponges are discarded into plastic lined receptacles?

  Yes

  No

  N/A

• 3.8. Circulator uses gloves when in contract with items from the sterile field?

  Safe

  At Risk

  N/A

• 3.9. Trash and linen are dropped into containers, they are not thrown?

  Yes

  No

  N/A

• 3.10. Contaminated instruments carried covered to decontamination room?

  Yes

  No

  N/A

• 3.11. Scrub personnel do an initial 3-minute scrub followed by 3-minute scrubs for consecutive cases with good techniques each time?

  Yes

  No

  N/A

4.0 Sterilization Process

• 4.1. Instruments contaminated with blood and body fluids are cleaned with disinfectant as soon as possible?

  Yes

  No

  N/A

• 4.2. Surgical instruments that fall from the sterile field are picked up (wearing gloves) and placed in a covered receptacle?

  Yes

  No

  N/A

• 4.3. If there is any doubt as to the sterility of equipment and supplies it is considered non-sterile?

  Safe

  At Risk

  N/A

• 4.4. All sterile packages are checked for integrity?

  Yes

  No

  N/A

• 4.5. Autoclave is monitored by Bowie Dick Test and Biological Spore Test?

  Yes

  No

  N/A

5.0. Storage Room

• 5.1. Floors and walls clean?

  Yes

  No

  N/A

• 5.2. Horizontal and vertical surfaces are clean?

  Yes

  No

  N/A

• 5.3. Adequate separation of clean and soiled?

  Yes

  No

  N/A

• 5.4. Bottom shelf is solid?

  Yes

  No

  N/A

• 5.5. No supplies stored 6" from the floor?

  Yes

  No

  N/A

• 5.6. No supplies stored touching the 18" from the ceiling?

  Yes

  No

  N/A

• 5.7. No supplies stored in the dirty utility room?

  Yes

  No

  N/A

• 5.8. Soiled linen is bagged accordingly?

  Yes

  No

  N/A

• 5.9. Are shoe covers, caps, masks and appropriate dress worn in sterile and sub sterile areas?

  Yes

  No

  N/A

• 5.10. Are the above items available for visitor who enters these areas?

  Yes

  No

  N/A

• 5.11. Are the doors to these areas kept closed?

  Yes

  No

  N/A

6.0. Chemical Safety

• 6.1. Material Safety Data Sheets available for all chemicals?

  Yes

  No

  N/A

• 6.2. Risk assessments completed for hazardous substance?

  Yes

  No

  N/A

• 6.3. All containers labelled correctly?

  Yes

  No

  N/A

• 6.4. Unused substances disposed of?

  Yes

  No

  N/A

• 6.5. Do special storage conditions apply?

  Yes

  No

  N/A

• 6.6. Workers trained in the use of hazardous substance?

  Yes

  No

  N/A

• 6.7. If required is PPE available?

  Yes

  No

  N/A

• 6.8. Are eye washes and showers easily accessed?

  Yes

  No

  N/A

7.0. Air Quality Control

• 7.1. Air conditioning filters changed on schedule and unobstructed?

  Yes

  No

  N/A

• 7.2. Non OR rooms kept at a constant temp between 20 and 24 degrees Celsius?

  Yes

  No

  N/A

• 7.3. Is OR kept between 18 and 20 degree celsius?

  Yes

  No

  N/A

• 7.4. Humidity level is kept between 30 and 60%?

  Yes

  No

  N/A

• 7.5. Linen is kept from being shaken?

  Yes

  No

  N/A

Additional Comments

• Additional Comments

Recommendations

• Investigator's Signature

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• Received by:

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