Information

  • Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

  • HCW performing insertion?

  • Patient cleans their hands & arms

  • Hand hygiene performed

  • Dressing packed used

  • Tray or kidney dish cleaned

  • All equipment gathered

  • Hand hygiene performed

  • Flush prepared

  • Patient arm placed on drape & pillow

  • Tourniquet applied

  • Vein located

  • Tourniquet released

  • Hand hygiene performed

  • Tourniquet reapplied

  • Gloves donned

  • Type of skin prep applied

  • Skin prep allowed to dry for min 30 seconds

  • No further repalpation

  • IV cannula successfully inserted

  • Sharp disposed immediately into container

  • Cannula flushed

  • Sterile dressing applied

  • Gloves removed & disposed

  • Hand hygiene performed

  • IV insertion site & date documented in medical records or care plan

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