Information

  • Audit Title

  • Conducted on

  • Prepared by

  • Location
  • Personnel

INFECTION PREVENTION

  • HAND HYGIENE

  • Team Members know where to access the MMH policy.

  • HH is practiced consistent with "the 5 moments" campaign.

  • Team Members are aware of the monitor and reporting.

  • Team Members are able to recall the MMH HH rate.

  • BLOODBORNE PATHOGENS

  • No food, drink, or cosmetics in patient care, specimen, or med areas.

  • Gloves are worn during vascular access

  • Team Members know what to do if an exposure occurs.

  • Sharps are handled appropriately - no recapping, active vs passive, etc.

  • No unattended sharps noted in area.

ISOLATION

  • Team Members know how to access the Isolation policy and appendix.

  • Team Members are familiar with types of isolation, how to institute, and the Infection Control Admission Assessment.

  • Negative and Positive air flow rooms function appropriately.

  • Team Members are knowledgable of AII (negative pressure) room controls and know where and when to document readouts.

  • Team Members are aware of contingency measures in AII rooms lose pressure.

  • Isolation signs posted as appropriate.

  • Team Members can locate appropriate PPE equipment.

  • PPE:<br> * Readily available<br> * Clearly marked<br> * Worn correctly<br>

NATIONAL PATIENT SAFETY GOAL 7

  • Goal 07.01.01 Hand Hygiene Monitors?

  • GOAL 07.03.01 MDRO -How do you prevent drug resistant organism spread?

  • GOAL 07.04.01 CLABSI - Who places central lines?<br> * What criteria do you use.

  • GOAL 07.05.01 SSI - Are Team Members educated on SSI?<br> * Are patients provided educations?

  • GOAL 07.06.01 CAUTI - Do Team Members recieve education as to how to prevent CAUTI?<br> * Are patients/families educated?

CLEANING

  • Equipment cleaning.<br> * Do Team Members know to follow equipment manufacturers instructions for cleaning.

  • Disinfectants are used on surfaces in accordance with manufacturers recommendations.

  • Patient care supplies: (including lab supplies)<br> * Not expired, damaged, soiled.

  • Patient care items: (including WOWs, vitals, PT items, etc. )are wiped down after each use in patient room.

  • Linen and Linen Carts: Covered and carts have solid bottoms.

  • General Cleanliness:<br> * Observe surfaces for high dust & residue, floors, stairwells, nutritional area, med prep areas, pt rooms & bathrooms<br> * No blood or bodily fluids.<br> * Survey Team Members in the area for opportunities.

  • Air vents: Clean inside and around.

  • Ice machines clean.

  • Water features are cleaned and maintained appropriately.<br>

REFRIGERATORS

  • Contain only those items designed for that refrigerator (specimen, medications or patient food)

  • If manually monitored, logs are complete. Both manual and temp track-documentation is present for actions taken to correct out of range temps.<br>

  • Patient items are dated and labeled as appropriate.

  • No expired items.

DESCRIBE THE DEPARTMENTS RESPONSE TO YOUR ARRIVAL

  • Greet the team with smiles and introductions.

  • Have a space designated for the team to conduct interviews and file reviews.

  • Promptly deliver materials required for review to the tracer team.

  • Any additional comments regarding positive or suboptimal issues observed during the tracer.

  • Surveyors Signature

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