Audit

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
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Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.