Title Page

  • Conducted on

  • Prepared by

  • Ward

  • Insert NM

  • Is the audit for a PIVC?

PIVC brand

  • Device Type

PIVC Bedside Review

  • Is the Date of Insertion marked on the dressing?

  • Is the PIVC connected to IV therapy on inspection?

  • Is there a BLUE line label present as per policy?

  • Is the approved IV occlusive dressing clean, intact and dry?

  • Is there tape or other non approved dressings securing the PIVC?

  • Has the patient been informed on how to care for the device and when to report concerns?

  • Is the PIVC in an appropriate anatomical position (should NOT be in Cubical fossa or poor position for patient comfort/safety unless otherwise documented by AP)

PIVC documentation review

  • PIVC observation chart or theatre records form has correct day of PIVC insertion documented

  • PIVC observation chart or Theatre Records has the correct anatomical site noted

  • PIVC observation chart or Theatre records has the correct gauge size documented

  • PIVC observation chart has insertion personnel documented

  • PIVC inserted by Ambulance service, during MET call, or by other facility or GP?

  • PIVC inserted >24 hours

  • Please write the insertion personnel name or location as documented on the form.

  • PIVC observation chart has PIVC inspection signed each shift

  • PIVC observation chart has correct day associated with the PIVC - day 1, 2 or 3

  • What is the Phlebitis Grading Score (PGS) at the time of audit?

  • Has the PIVC been used since insertion (such as to give fluid or IV AB)?

  • Documentation that PIVC flushed every 8hrs (when not in use)

  • PIVC in-situ > 72 hours

  • Is the audit for a CVL or PICC?

Invasive Device

  • Invasive device assessment form completed?

  • Tegaderm 3000 dressing applied without reinforcement (tape) after day 1

  • Date of latest dressing change on dressing

  • Is device line secure to avoid dislodgement

  • Is device free from kinks on asking patient to move arm?

  • Does the PICC line have bungs on all lumens?

  • Is there any visible blood/medication in the lumens?

  • Is the dressing clean and intact?

  • Is there blood present under dressing? If yes please change dressing ASAP

  • Is the CVC still in use?

  • Is there documentation to support why the CVC is still insitu and not active?<br>


  • Have the nursing staff caring for the invasive device completed the CVC & PICC competency

  • Has the site been checked once per shift?

  • Is there documentation to support device inserted using ANTT

  • Invasive devices anatomical location documented

  • Is type and location of device clearly documented?

  • Is the PICC batch number documented for devices inserted in SCR or ICU/Theatre

  • Staff member that inserted device has documented their details

  • Line changes documented as per policy

  • Patient or family given care information sheet

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.