Information
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Employee:
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Conducted on
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Prepared by
Hand Hygiene and Garbing Practices
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Remove all jewelry from hands, wrists, and above neck?
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Scrubs nails, hands, and arms (to elbows) with water and disinfecting agent for at least 30 seconds?
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Rinses hands and arms holding hands upright to allow water to drip down to elbow?
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Proper garbing sequence: shoe covers, head cover, mask, hand hygiene, gown, and gloves?
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After entering IV Room, disinfects hands with alcohol-based hand scrub, allows hands to dry dry before donning sterile gloves?
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Can explain proper method to routinely disinfect gloves with sterile 70% isopropyl alcohol prior to entering hood?
Ante Room- IV Room Product Transfer
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Understands concept of "dirtiest to cleanest" when transferring product to IV Room?
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Understands all products are misted. With sterile 70% isopropyl alcohol on Ante Room cart prior to transfer to IV Room
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Individual preparation baskets are disinfected with sterile 70% isopropyl alcohol?
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Understands products must be disinfected with sterile 70% isopropyl alcohol prior to restocking the Ante Room?
Horizontal Laminar Flow Hood
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If hood turned off: minimum time (30 minutes) required to run prior to any IV preparations?
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Does not utilize outer 6 inches of hood work surface or within 6 inches of back/sides of hood?
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Uses sterile 70% isopropyl alcohol wipes to clean hood. Does not use spray bottle?
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Understands horizontal airflow and avoids blocking first air to critical sites during sterile compounding?
Ampule Preparation
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Ampule neck clear of fluid, cleaned with alcohol and wrapped with alcohol swab or plastic amp breaker prior to breaking open?
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Breaks ampule correctly and away from the HEPA filter?
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Utilizes filter needle or straw with contents of ampule?
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Removes filter needle and replaces with needle prior to injecting final container?
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Uses proper technique to avoid contamination of needle, plunger, or syringe?
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Cleans additive port on container prior to injecting medication?
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Recaps needle using one-handed "scoop method"?
Vial Preparation
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Removes vial dust cover and properly disinfects vial stopper with sterile 70% isopropyl alcohol swab?
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Inserts needle correctly with bevel side up to reduce coring?
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Inserts appropriate amount of air into vial to aid in removal of product?
Compounded Sterile Preparation Label
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Aware of resources to determine appropriate beyond-use dating for prepared products?
Compounding of Sterile Neonatal and Pediatric Preparations
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Understands how to utilize neonatal and pediatric dilution tables for IV preparation?
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Selects correct Julian date for lot number to identify pool bag compounded for neonatal/pediatric preparations?
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Process to assemble and prepare components of batch bag for pharmacists to review prior to compounding?
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Understands components of label on neonatal/pediatric batch bags?
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Correctly determines beyond-use dating of compounded neonatal/pediatric preparations?
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Understands how to complete Neo/Ped batch bag compound log and specific ped patient IV compound dose log?
QI Medical PATT 2 Media Fill Testing
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Media Lot:
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Expiration:
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Incubation period 14 days:
7 days room temperature and 7 days incubator -
Results:
TSA Agar Plate Gloved Fingertip Sample Post Garbing-Cfu (colony forming unit)
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Initial validation (3 samples) or Revalidation (1 sample)
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Target=zero colony forming units
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Incubation period: 2 days (30-35 degrees C)
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Right Glove Cfu:
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Left Glove Cfu:
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Lot:
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Expiration:
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Select date
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Right Glove Cfu:
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Left Glove Cfu:
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Lot:
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Expiration:
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Select date
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Right Glove Cfu:
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Left Glove Cfu:
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Lot:
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Expiration:
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Select date
TSA Agar Plate Gloved Fingertip Sample Post Media Fill Testing
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Target=three or less colony forming units
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Incubation period: 2 days (30-35 degrees C)
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Right Glove Cfu:
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Left Glove Cfu:
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Lot:
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Expiration:
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Select date
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Right Glove Cfu:
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Left Glove Cfu:
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Lot:
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Expiration:
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Select date
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Add signature
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Select date
