Audit

General Infection Control Practices & Safety

Staff can locate Infection Prevention Policies

Staff can articulate and locate the Bloodborne Pathogen Exposure Policy

Staff can locate the SDS

Appropriate PPE available

Staff is observed using PPE appropriately

PPE is disposed at point of use

Sinks properly located and functioning

Hand washing stations/ scrub sinks are stocked with towels, soap, surgical hand scrub, nail cleaners and brushes

Waterless surgical scrub available

Hand Hygiene before and after patient care

Hospital approved hand lotion is available

No artificial nails/products worn by direct patient care staff

No staff food, drinks, cosmetics, applying of contact lenses, use of personal lotions, or storing of personal items in patient care areas

Hospital approved disinfectant is available

Staff correctly observe isolation precautions posted for patients

Single use items (scissors, tweezers) not re-used

Enzymatic cleaner available in each IR

CLEANING
No High Dust Present

Supply cabinets are clean and dust/rust free

Air vents/ air supply grills are clean and dust free

No dust or rust on equipment or supplies. No damaged equipment or supplies

Patient monitors

IV Poles and pumps

Head Lights

Medical gas gauge

Mayo stands

Hampers (if any)

Exam table, including bottom of table

Computer and keyboards dust free and clean

Equipment is cleaned according to manufacturer's recommendations

Equipment is with current inspection stickers

All appliances for prep/storage of medications are visibly clean

No tape residue on equipment or on table

No tape residue anywhere in the IR

Anesthesia cart is clean. All drawers free of dust and clutter.

All other carts in the IR: clean and no tape residues on the inside. All drawers are free of dust and clutter.

IR suite properly stocked without clutter

Patient table clean, no dirt, bodily fluids, rust... found when broken down

Stands, kick buckets clean (if applicable)

Wheels, furniture, lights clean (no rusty wheels)

Door handles are clean

All other surfaces free of dust and debris

Ceiling tiles are in place, dry and free from stains, cracks, and holes

Hallways are clean and free of clutter

Walls free of breaks and penetrations, tape residue, dried bodily fluids

IR is cleaned between patients and at the end of the day per policy

Mattresses /cushions are clean with no holes / cracks / tears

EVS closet is clean, organized and secure

Storage

Clean utility room is clean and organized

Storage units /bins/shelving are clean and organized

Sterilized trays are free of dust, unopened, no tears

Supplies > or = to 18" from ceiling and 10" above floor on lined shelving

Storage of supplies is clean and organized

No items stored on the floor

No expired supplies

No torn or compromised supplies

Items are stored in a manner that will not compromise sterility (compressed, crushed, susceptible to tears, away from sources of moisture)

Supplies are not stored where food/ drinks are consumed. (or no food /drinks in supply room)

Linen carts/ room are clean and organized

Linen carts in hallways or combines storage rooms are covered.

Clean equipment is stored separately from soiled equipment

Dirty Utility Room is labeled, clean and organized.

Inappropriate or unnecessary equipment and supplies are not present in the area

Items are stored in appropriate or safe locations (nothing on top of trash containers, shred bins, blocking hallways, doors or exits)

All medications are secured with access only to authorized hospital personnel. narcotics are secured and stored separate from other medications

All open vials of medications have an expiration date from the manufacturers with no obvious signs of contamination, and are dated when opened. Multi-dose vials expire within 28 days of opening (USP 797)

Refrigerator thermometers reads 36-45 degrees Fahrenheit

Refrigerator and freezer logs are read at least twice a day (twice if used to store vaccines) (CDC)

Refrigerator and freezer temperature logs are dated and signed by the person performing the check and are readily available if requested (CDC)

Staff able to articulate the action taken if temperature is out of range

Corrective action is documented if temperature is out of range

Anesthesia Cart

When unlocked by appropriate staff, no expired medications found

No evidence of reuse of single dose vials

Intubation equipment sealed in unopened peel packs, clean and sterilized

IR Desk / Work Room

Free of clutter

No food or drink

No laboratory samples at desk

Supply Cabinets in the IR

Supply cabinets: No high dust

Bottom of all shelves lined

No expired equipment during spot check

No expired supplies during spot check

Cabinets kept closed at all times

Waste Management

Biohazardous waste containers do not hold regular trash

No biohazardous waste in the regular trash containers

Waste holding areas and carts are clean

Sharps containers are secured

ONLY sharps in sharps box

Sharps boxes <2/3 full

Nothing on top of sharps boxes

Dirty linen hamper is no more than 3/4 full

Dirty linen is covered and transported in leak resistant container

Soiled Utility Rooms

Cleaning products stored properly

Mop water and buckets clean

Cleaning tools clean

Adequate supply of cleaning materials

Soiled materials segregated

Floors clean

PPE available

Red bags tied properly

Trash bins clean

Hallways/Scrub areas

All storage to one side of hall

No unlabeled and unattended cleaning products in the hall

Scrub sinks, foot pads clean and free of rust

Staff able to articulate correct storage of lead aprons (according to policy/ manufacturer's recommendation.)

Staff able to articulate cleaning and disinfection of lead aprons in between use.

Radiology equipment clean and properly stickered (PM).

Staff and Space / Work Flow

Hand hygiene before and after procedure done.

Hair covered: scalp and facial hair

Ears covered with scrub cap

PPE worn as appropriate

IR staff at bedside in proper sterile attire

Scrub top tucked in for all IR staff scrubbed in for a procedure

No fleece sweaters, warm up clothing

No obvious signs of infection (ex. respiratory, skin) noted

Doors are not propped open

Egress corridors are free from obstruction

Staff Knowledge

Staff able to articulate the 5 moments of hand hygiene

Staff able to articulate the care of instruments at point of care.

Staff able to articulate how isolation patients are identified.

Other Findings

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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.