Information

  • Employee

  • Conducted on

  • Prepared by

Hand Hygiene and Garbing Practices

  • Removes all jewelry from hands, wrist, and above neck?

  • Scrub nails, hands, 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 elbows?

  • Uses disposable non-shedding towels to dry hands?

  • 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 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 FlowHood

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

  • Cleans hood in proper order: IV pole, sides, and bottom working top to bottom and back to front?

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

  • Uses sterile70% 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 to remove 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 IV diluent bag with alcohol pad prior to injecting medication?

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

Vial Preparation

  • Removes vial dust cover and properly disinfects vial stopper with sterile70% 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?

USP Chapter 797 Daily Documentation

  • Understands required documentation of daily tasks for each shift?

Compounding of Sterile Neonatal and Pediatric Preparations

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

  • Selects correct Julian date for lot number to identify pool bag compounded for 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?

TPN

  • Understands process to spike and attach administration set to TPN bag?

  • Use of inline filter: 0.2 micron?

Daily/Monthly Cleaning and Disinfecting Procedures

  • Horizontal hood cleaning and disinfecting schedule: first of shift, prior to batch, and as needed during compounding?

  • Mop handles designated for floors, walls, and ceiling?

  • Cleaning product (obtained by EVS) used only for mopping IV Room and Ante Room?

  • Use of spray bottles of sterile 70% isopropyl alcohol and sterile low-lint wipes for daily cleaning of work surfaces and IV Room carts?

  • Trash removal procedure for IV Room and Ante Room?

  • Locates reference indicating monthly cleaning procedures/cleaners/areas?

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

  • 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

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