Information

  • Employee:

  • Conducted on

  • Prepared by

Hand Hygiene and Garbing Practices

  • Remove all jewelry from hands, wrists, and above neck?

  • Scrubs nails, hands, and arms (to elbows) with water and disinfecting agent for at least 30 seconds?

  • Rinses hands and arms holding hands upright to allow water to drip down to elbow?

  • Proper garbing sequence: shoe covers, head cover, mask, hand hygiene, gown, and gloves?

  • After entering IV Room, disinfects hands with alcohol-based hand scrub, allows hands to dry dry before donning sterile gloves?

  • Can explain proper method to routinely disinfect gloves with sterile 70% isopropyl alcohol prior to entering hood?

Ante Room- IV Room Product Transfer

  • Understands concept of "dirtiest to cleanest" when transferring product to IV Room?

  • Understands all products are misted. With sterile 70% isopropyl alcohol on Ante Room cart prior to transfer to IV Room

  • Individual preparation baskets are disinfected with sterile 70% isopropyl alcohol?

  • Understands products must be disinfected with sterile 70% isopropyl alcohol prior to restocking the Ante Room?

Horizontal Laminar Flow Hood

  • If hood turned off: minimum time (30 minutes) required to run prior to any IV preparations?

  • Does not utilize outer 6 inches of hood work surface or within 6 inches of back/sides of hood?

  • Uses sterile 70% isopropyl alcohol wipes to clean hood. Does not use spray bottle?

  • Understands horizontal airflow and avoids blocking first air to critical sites during sterile compounding?

Ampule Preparation

  • Ampule neck clear of fluid, cleaned with alcohol and wrapped with alcohol swab or plastic amp breaker prior to breaking open?

  • Breaks ampule correctly and away from the HEPA filter?

  • Utilizes filter needle or straw with contents of ampule?

  • Removes filter needle and replaces with needle prior to injecting final container?

  • Uses proper technique to avoid contamination of needle, plunger, or syringe?

  • Cleans additive port on container prior to injecting medication?

  • Recaps needle using one-handed "scoop method"?

Vial Preparation

  • Removes vial dust cover and properly disinfects vial stopper with sterile 70% isopropyl alcohol swab?

  • Inserts needle correctly with bevel side up to reduce coring?

  • Inserts appropriate amount of air into vial to aid in removal of product?

Compounded Sterile Preparation Label

  • Aware of resources to determine appropriate beyond-use dating for prepared products?

Compounding of Sterile Neonatal and Pediatric Preparations

  • Understands how to utilize neonatal and pediatric dilution tables for IV preparation?

  • Selects correct Julian date for lot number to identify pool bag compounded for neonatal/pediatric preparations?

  • Process to assemble and prepare components of batch bag for pharmacists to review prior to compounding?

  • Understands components of label on neonatal/pediatric batch bags?

  • Correctly determines beyond-use dating of compounded neonatal/pediatric preparations?

  • 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

  • Media Lot:

  • Expiration:

  • 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)

  • Initial validation (3 samples) or Revalidation (1 sample)

  • Target=zero colony forming units

  • Incubation period: 2 days (30-35 degrees C)

  • Right Glove Cfu:

  • Left Glove Cfu:

  • Lot:

  • Expiration:

  • Select date

  • Right Glove Cfu:

  • Left Glove Cfu:

  • Lot:

  • Expiration:

  • Select date

  • Right Glove Cfu:

  • Left Glove Cfu:

  • Lot:

  • Expiration:

  • Select date

TSA Agar Plate Gloved Fingertip Sample Post Media Fill Testing

  • Target=three or less colony forming units

  • Incubation period: 2 days (30-35 degrees C)

  • Right Glove Cfu:

  • Left Glove Cfu:

  • Lot:

  • Expiration:

  • Select date

  • Right Glove Cfu:

  • Left Glove Cfu:

  • Lot:

  • Expiration:

  • Select date

  • Add signature

  • Select date

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.