Tristel Wipes

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

Chart UR Number

• MRN number of chart audited

Staff

• The staff member who has high disinfected the nonlumen medical device is Tristel Wipe Competent

  Yes

  No

  N/A

• Staff member has not used Tristel wipes in > 6 months

• Staff member has not used Tristel wipes in > 12 months

• Has documented evidence of processing a minimum of 4 nonlumen medical devices per month to maintain their skill

  Yes

  No

  N/A

• Evidence found but not up to date

Device

• Device details and Serial number complete

  Yes

  No

  N/A

• No Serial Number

• No device details

• Date and Time processed complete

  Yes

  No

  N/A

• No Time

• No Date

• Incorrect information

Pre - Cleaning

• Tristel PreClean Wipe used

  Yes

  No

  N/A

• Lot number and Use by date complete

  Yes

  No

  N/A

• No use by date

• No lot number

Sporicidal Wipe

• Two pumps of activator foam was used

  Yes

  No

  N/A

• Only one pump

• Step missed

• Scrunching of wipe with activator foam for 15 clock seconds

  Yes

  No

  N/A

• Step missed

• Disinfection remaining on medical device for minimum of 30 clock seconds

  Yes

  No

  N/A

• Step missed

• Traceability label has been completed with activator foam lot number and affixed to tracking book

  Yes

  No

  N/A

• No Label

• Labels incorrect

• Labels illegible

Rinsing Method

• Tristel Rinse Wipe used

  Yes

  No

  N/A

• Lot number and Use by date complete

  Yes

  No

  N/A

• No use by date

• No lot number

Destination Device

• If device stored was patient’s notes label (from sporicidal sachet) affixed to storage box

  Yes

  No

  N/A

• Wrong labels

• If device stored, was storage container cleaned, tracking book stamped with signature of person who has completed this

  Yes

  No

  N/A

• Tracking book not stamped

• Signature of person not in book

• If device used for a patient, patient label has been affixed to tracking book and Patient’s Notes Label has been affixed to intraop report

  Yes

  No

  N/A

• No label in Pt's notes

• Sticker not correctly affixed to intra-op report

• No Patient label affixed to tracking book

Confirmation

• Person who has cleaned highly disinfected device has printed and signed their name

  Yes

  No

  N/A

• No printed name

• No date

• No time

• No Signature

Microbiology

• Device has been microbiologically tested within the past 3 months (IF required)

  Yes

  No

  N/A