UM WalkRound Cross Audit - Endoscopy

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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)

  MET

  NOT MET

  N/A

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

  MET

  NOT MET

  N/A

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

  MET

  NOT MET

  N/A

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

  MET

  NOT MET

  N/A

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

  MET

  NOT MET

  N/A

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

  MET

  NOT MET

  N/A

• 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

  MET

  NOT MET

  N/A

• 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

  MET

  NOT MET

  N/A

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

  MET

  NOT MET

  N/A

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