Pharmacy Cleaning Checklist

• Site

• Address
  Address

• Checked by

• Conducted on

  Date

Cleaning & Disinfecting

• Is the pharmacy and areas where medications are stored, compounded, dispensed, prepared, and administered clean?

  Yes

  No

  N/A

• Does the staff use organization–approved cleaning procedures and cleaning and disinfecting agents?

  Yes

  No

  N/A

• Is there an adequate number of sinks and sufficient space and materials for cleaning equipment and washing hands?

  Yes

  No

  N/A

• Are alcohol-based hand rub containers appropriately located?

  Yes

  No

  N/A

• Are cleaning agents and supplies readily available to staff?

  Yes

  No

  N/A

• Are cleaning and disinfecting agents appropriately labeled and diluted?

  Yes

  No

  N/A

• Is equipment kept clean and stored in a clean area? (Note: Areas under sinks are not clean areas. Mortars, pestles, glassware, and other equipment that must be kept clean must be stored in a clean area.)

  Yes

  No

  N/A

• Are drug preparation, packaging, and dispensing devices (e.g., mortars, pestles, pill crushers, pill splitters, counting trays, graduated cylinders, unit-dose packaging devices, and balances) cleaned after each use and disinfected, if necessary?

  Yes

  No

  N/A

• Are devices used for crushing or splitting tablets cleaned immediately after use according to manufacturers’ recommendations and instructions?

  Yes

  No

  N/A

• Are medication carts, drawers, and bins containing individual patient’s medications kept clean?

  Yes

  No

  N/A

• Are automated dispensing cabinets and bins cleaned according to the manufacturer’s recommendations and instructions?

  Yes

  No

  N/A

Boxes & Storage

• Are cardboard boxes stored off the floor?

  Yes

  No

  N/A

• Are shipping containers not stored or opened (i.e., torn or cut) in any area reserved for prepackaging medications or compounding sterile preparations? (Note: Handling and storing shipping containers (e.g., cardboard boxes) must be done with minimal air disturbances and dissemination of dust particles. Intravenous (IV) bags and bottles and related supplies must be removed from cartons and wiped with an approved disinfecting agent prior to placing them in the sterile preparation area.)

  Yes

  No

  N/A

Waste

• Does staff dispose of waste in accordance with the organization’s infection control policies and procedures?

  Yes

  No

  N/A

• Are waste disposal containers close to the area of use?

  Yes

  No

  N/A

• Is noninfectious waste not mixed with infectious waste?

  Yes

  No

  N/A

Infectious Waste

• Does staff dispose of infectious waste in accordance with the organization’s infection control policies and procedures?

  Yes

  No

  N/A

• Are infectious waste disposal containers close to the area of use?

  Yes

  No

  N/A

• Is infectious waste placed in specially marked containers (e.g., red bags) and disposed of separately from routine trash?

  Yes

  No

  N/A

• Are items used in patient rooms not returned to the pharmacy?

  Yes

  No

  N/A

Attire

• Does personnel wear appropriate attire in non-sterile areas?

  Yes

  No

  N/A

• Is attire worn in the sterile compounding area clean and minimizes the potential for shedding and contamination, and meets the organization’s policy and state regulations?

  Yes

  No

  N/A

• Does personnel remove jewelry and cosmetics prior to compounding sterile preparations?

  Yes

  No

  N/A

Hygiene

• Does personnel with rashes, sunburn, weeping sores, conjunctivitis, or active respiratory infection not prepare sterile preparations?

  Yes

  No

  N/A

• Does fingernail length comply with the organization’s policies and procedures?

  Yes

  No

  N/A

• Does the use of artificial fingernails comply with the organization’s policies and procedures?

  Yes

  No

  N/A

• Is routine hand washing performed at the beginning of the shift, after visiting the restroom, before and after eating, and when the hands are obviously soiled? (The areas under the fingernails must be kept clean.)

  Yes

  No

  N/A

• Does staff use a hand washing technique and cleaning agents that are approved by the organization?

  Yes

  No

  N/A

Sterile Preparation Compounding

• Does personnel wash their hands thoroughly prior to compounding sterile preparations?

  Yes

  No

  N/A

• Does personnel who leave the sterile preparations compounding area rewash their hands prior to resuming compounding?

  Yes

  No

  N/A

• Do areas for compounding sterile preparations minimize opportunities for particulate and microbial contamination of the preparations?

  Yes

  No

  N/A

• Are floors in the ante and buffer areas cleaned in accordance with USP <797> requirements?

  Yes

  No

  N/A

• Are all compounded sterile preparations labeled with beyond-use dates?

  Yes

  No

  N/A

• Are compounded sterile preparations quarantined and inspected by a pharmacist prior to release from the pharmacy? (When possible, the individual who performs the inspection should not be the individual who compounded the preparation)

  Yes

  No

  N/A

Primary Engineering Controls (PEC)

• Are sterile preparations compounded in a properly maintained laminar airflow workbench, biological safety cabinet, compounding aseptic isolator, or compounding aseptic containment isolator?

  Yes

  No

  N/A

• Are compounding of medium- and high-risk preparations, parenteral nutrition, antineoplastic and other hazardous agents, cardioplegia, and other preparations that require specialized knowledge or equipment usually found only in the pharmacy compounded in the pharmacy by specially trained staff?

  Yes

  No

  N/A

• Are primary engineering control surfaces cleaned and disinfected frequently, including at the beginning of each work shift, before each batch preparation is started, every 30 minutes during continuous compounding activity, when spills occur, and whenever surface contamination is known or suspected?

  Yes

  No

  N/A

• Is USP Purified Water used to remove water-soluble residues, and then the same surfaces are disinfected with a non-residue generating agent using a lint-free wipe? (Note: Most organizations use sterile 70% isopropyl alcohol as the disinfectant. Other agents may be used if approved by the organization)

  Yes

  No

  N/A

• Are all items (including syringes, vials, and other extraneous items) removed from the hood before cleaning it? (Note: Infection-control policies and procedures should include a schedule and technique (including cleaning agent) for cleaning primary engineering controls (laminar air flow workbenches, biological safety cabinets, compounding aseptic isolators, and compounding aseptic containment isolators). Clean the work surface, side panels, and other accessible surfaces, starting at the top and rear and working downward and toward the front, unless the manufacturer recommends a different procedure.)

  Yes

  No

  N/A

• Is routine maintenance, such as cleaning or replacing prefilters, performed regularly and according to manufacturers’ specifications (e.g., monthly or quarterly)?

  Yes

  No

  N/A

• Are HEPA filters replaced or repaired when recommended by a qualified certifier?

  Yes

  No

  N/A

• is environmental monitoring of both non-viable (e.g., particles) and viable (e.g., microbial or fungal contamination) performed as required (e.g., by USP <797> and/or state regulations)?

  Yes

  No

  N/A

• Are results of environmental monitoring reported to the management?

  Yes

  No

  N/A

• Are primary engineering controls checked and certified when they are first placed in service, at least every 6 months, when maintenance is completed, or they are moved to a new location? (Note: Certification of primary engineering controls is usually documented by placing a sticker on the device and keeping inspection records on file.)

  Yes

  No

  N/A

• Are checks of operational efficiency of all primary engineering controls, ante areas, and buffer areas performed at least once every 6 months by a qualified certifier?

  Yes

  No

  N/A

Aseptic Technique

• Is a sterile syringe used for each medication withdrawn?

  Yes

  No

  N/A

• Are syringes used on one patient only and then disposed of properly?

  Yes

  No

  N/A

• is a sterile needle used for each medication withdrawn?

  Yes

  No

  N/A

• Are containers for disposal of used needles and other sharp objects available, used properly, and not overfilled?

  Yes

  No

  N/A

Single-Use Containers

• Are single-use containers not reused?

  Yes

  No

  N/A

• Are single-use containers discarded immediately after use in accordance with the organization’s policies?

  Yes

  No

  N/A

Multiple-Dose Containers

• Are multiple-dose containers that will be reused after the first puncture labeled with an appropriate beyond-use date? (Note: All multiple-dose containers intended for reuse must be labeled with a beyond-use date whether they are labeled with the date of the first entry or not.)

  Yes

  No

  N/A

• Are multiple-dose containers not used beyond the time specified by the organization’s policies? (The time period must not exceed 28 days unless a longer time period is specifically referenced in the package insert for the product. Whatever the policy, the period must not conflict with the manufacturer’s recommendations nor extend beyond the manufacturer’s expiration date.)

  Yes

  No

  N/A

• Are pharmacy bulk packages of electrolytes and other products used in the pharmacy for no more than 4 hours after the initial entry into the container unless the manufacturers’ product information provides for another time period? Any unused portions are discarded.

  Yes

  No

  N/A

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