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UM WalkRound Cross Audit - Endoscopy

ENDOSCOPY UNIT (2 standards, 1 sub-standard with 7 sub-points)

  • IPC.17 The hospital ensures environmental safety when disinfectants are used outside the central sterilization service. (Observation)

IPC.17.1 In endoscopy units, a proper approved disinfectant is used in a way to protect the patient, the staff and the environment from possible infectious hazard (Observation)

  • IPC.17.1.1 The procedure room and the decontamination room are physically separated and the decontamination room has infection control requirements to prevent spread of infection to healthcare workers and to patients

  • IPC.17.1.2 Appropriate personal protective equipment (respirator, gloves: nitrile or butyl rubber, goggles and gowns) are used

  • IPC.17.1.3 Unauthorized persons are not allowed in the processing area

  • IPC.17.1.4 Well closed containers are used to keep the disinfectant solution

  • IPC.17.1.5 A policy and procedure is implemented on how the endoscope is processed (cleaning, decontamination, and disinfection) between patients

  • IPC.17.1.6 Endoscopes are cleaned with disposable brushes or with reusable brushes that are sterilized after every use. Heat-stable parts and accessories of the endoscopes such as biopsy forceps are cleaned by mechanical cleaners and stabilized after use

  • IPC.17.1.7 Quality tests (strips or other method) used to confirm the stability of the disinfectant are performed every day and records are maintained

  • AN.15 Qualified staff perform moderate and deep sedationanalgesia. ESR Staff Interview & Document Review (Staff File)


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