Title Page

  • Conducted on

  • Prepared by

  • Site

  • MRNs (If applicable)

IPC Inpatient Audit Checklist

General

  • Eating, drinking, and storing food in dedicated pantry room or area

Dress Code

  • All staff in the department are complying with their dress code

  • Doctors wear clean lab coat with buttons closed

Hand Hygiene

  • There are dedicated hand wash sinks with adequate supplies (soap & paper towels)

  • Adequate number of alcohol based hand rub dispensers are available

  • Soap is never added to partially empty soap dispensers

  • Liquid soap dispensers are cleaned with soap and water and disinfected with chlorine daily before refill

  • Finger nails are kept short, clean, and free from nail polish

  • Staff do not wear jewelry or rings

  • Compliance with hand wash/alcohol rub according to five moments

PPE

  • Adequate and proper PPE are available

  • Surgical mask wear on entering patients’ rooms

  • Proper PPE wear according to the procedure done

  • Proper PPE donning and removal

Patients Hygiene

  • Daily shower with antiseptic soap containing chlorhexidine (e.g. Cyteal®)

Blood Sampling / Cannulation Aseptic Technique

  • Preparation of supplies/tray (Using one trial medication bag)

  • Doing hand hygiene with alcohol based hand rub solution

  • Wearing gloves (sterile in cannulation)

  • Using disposable tourniquet

  • Proper skin preparation: Using sterile gauze soaked with Cyteal® then drying, followed by alcohol swab and waiting for dryness

  • Compliance with the “No Touch Technique”

  • No recapping for the used syringes or needles

  • Proper waste segregation

  • Removal of gloves and alcohol rub

Parenteral Medications

  • Medication carts are maintained clean and dry

  • Aseptic technique is used during parenteral medications withdrawal

  • Multi-dose vials are labeled with the date and time of opening

  • Multi-dose vials are discarded 28 days after first use unless the manufacturer specifies otherwise Only ONE multi-dose vial is used at a time

  • Single-dose/single-use vials are used within one hour from initial opening, with any remaining contents discarded

  • Medications are injected as soon as feasible and within 1 hour after drawing up into syringes

Isolation Precautions

  • Isolation sign is placed on the door and is clearly visible to all who enter the room

  • PPE according to type of isolation are available & used upon entry to room:

  • Airborne: High efficiency mask (N95) and discarded after leaving the room

  • Droplet: Surgical mask and discarded after leaving the room

  • Contact: Clean gloves and long sleeves gown and discarded before leaving the room.

Reprocessing of Medical Instruments and Equipment

  • Rinsing of contaminated instruments and equipment and collection in covered container immediately after use

  • Glucometers are wiped between patients with alcohol swab

  • Stethoscopes and blood pressure cuffs are disinfected between patients

  • Laryngoscopes are sterilized between patients

  • Oxygen humidifier is sterilized between patients & every 24 hours for same patient

  • Sterile water is used to fill humidifiers

  • Suction bottles and tubing are reprocessed daily for the same patient

Storage of Supplies / Medications

  • All supplies are clean, dry and stored in a proper way

  • No supplies or items are stored on the floor or under the sinks

  • Refrigerators are clean and contain only drugs

  • Refrigerators’ temperature is recorded daily

  • No expired supplies / medications are observed

Blood Exposure Management

  • Proper blood exposure management as per policy

Linen Management

  • Proper collection of used linen from patients’ rooms

  • Proper transport of linen from department to laundry using covered carts

  • Linen is changed daily, when contaminated, and between patients

  • Mattresses and pillows are covered with protective water proof cover

Environmental Safety

  • Proper environmental surfaces cleaning and disinfection (daily and when contaminated)

  • Equipment surfaces and computers’ keyboards are cleaned and disinfected by the approved disinfectant (daily and when contaminated)

  • Proper management of blood spillage

Waste Management

  • Proper waste segregation using colored bags and sharp containers

  • Proper time of collection of waste bags

  • Waste bags are tied, labelled, and placed in the dirty utility room

Playing Room

  • Patients are given instructions for hand hygiene before and after playing

  • Toys are cleaned and disinfected between patient uses, and as per policy (Toys’ units “twice/week”, stationary toys “daily”)

HVAC

  • Ducts & Filters of air conditioning system are cleaned as per policy

  • Monitoring for air pressure in isolation rooms

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