Download Safe Injection Practices Infection Prevention Audit Tool

Safe Injection Practices Infection Prevention Audit Tool
Unit/Dept/Clinic: _________________________________
Date: _______________________________
Completed by: ___________________________
*All practices found to be not satisfactory require an action to be listed in the comments area.
Practice to be Assessed
ASEPTIC TECHNIQUE
1. Hand hygiene is performed (soap/water or hand sanitizer)
prior to accessing supplies, handling vials and IV solutions, and
preparing or administering medications.
2. Disposable gloves are worn according to HealthEast
policy/procedure.
3.
Medications and supplies are stored and prepared in a clean
area on a clean surface.
4.
Needles and syringes are stored in their original
packaging/wrapper. They are not stored unwrapped as
sterility cannot be assured.
Skin at the injection/insertion site is prepared with the
appropriate antiseptic which is allowed to dry on the skin.
5.
6.
The injection site is not touched after skin antisepsis has been
done.
NEEDLES/SYRINGES
7. Sterile, single use syringes are always used for any type of
injection or infusion. Manufacturer prefilled syringes are
always used for only one patient.
8. Needles, cannulas and syringes are always used as single use
(used for only one patient) and are never re-used on other
patients or to access medications/solutions more than once.
9. Medications are never administered from the same syringe or
needle to more than one patient. Changing the needle but
not the syringe is unacceptable.
10. The sterile needle/cannula and/or syringe is removed from
the packaging just prior to use. Storage of syringes removed
from packaging (even with capped needle) is prohibited.
11. Medications are not prepared in one syringe and then
transferred to another syringe.
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Satisfactory
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Satisfactory*
N/A
Comments
Practice to be Assessed
VIALS
12. Single-use or single-dose vials are used whenever possible.
Single-dose (single-use) medication vials are only used for one
patient. Discard after one use.
13. Entry into a medication vial is always done with a new needle
or cannula and syringe – these items are single use only.
Never enter a vial with a syringe or needle that has been used.
14. The rubber septum/diaphragm of medication vials is always
cleansed using friction with alcohol prior to each entry.
15. Multi-dose vials are dated when first opened and discarded
within 28 days of opening or according to manufacturer’s
recommendations.
16. Left over parenteral medications are never pooled or
combined for later use.
17. Needles and cannulas are never left inserted in any vial rubber
septum for multiple withdrawals.
18. Vial spikes for use in multi-dose vials, which maintain a closed
system with no opening to the air (i.e. Clave Multi-dose vial
adapter), can be accessed multiple times for as long as the vial
is in use. The vial adapter is to be scrubbed with alcohol
before each entry.
19. Pre-drawing of medications:
A. Meds drawn up on a unit or in clinic (outside of Pharmacy)
are considered immediate use and need to be given within
one hour. Labeling should include: date, time drawn, initials
of person drawing, med name and dose, expiration time (<24
hrs).
B. Perioperative or Procedural Settings for meds not
immediately used: label all meds, med containers, & other
solutions on and off the sterile field (ie syringes, med cups,
and basins). This applies even though only one med might be
used. Labeling should include: med name, strength, quantity,
diluents & volume (if not apparent from the container),
expiration date/time (<24 hours)
20. Medication vials are inspected prior to use and if sterility has
been or is thought to be compromised (presence of
particulate matter, discoloration, turbidity) it is discarded.
Manner of
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Satisfactory
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Satisfactory*
N/A
Comments
Practice to be Assessed
IV SOLUTIONS
21. Bags/bottles of IV solutions are never used as common source
supply (i.e. flush solutions) for more than one patient.
22. Infusion supplies such as needles, syringes, flush solutions,
administration sets, IV fluids are never used for more than
one patient.
23. Administration of spiked IV solutions is initiated within 1 hour
of preparation. If administration has not begun within one
hour of spiking bag, the IV and tubing is discarded.
BLOOD GLUCOSE MONITORING
24. Restrict use of finger stick capillary blood sampling devices to
individual patients.
25. Use single-use lancets that permanently retract upon
puncture. Never reuse finger stick devices and lancets.
26. Pen style devices with removable lancet must be dedicated to
one patient and lancets removed by patient or if by healthcare
worker with mechanical means (hemostat) to avoid contact.
27. Clean and disinfect the exterior surface of glucometer after
each use, even if there is not visible blood/soil. Only use EPA
registered disinfectant approved by Infection Control.
SHARPS SAFETY
28. Needles/sharps are disposed of at the point of use.
Containers are located conveniently in areas where sharps are
used.
29. Sharps disposal containers are leak-proof, puncture-resistant
and are red/orange in color or labeled with a biohazard label.
30. Sharps containers are emptied/replaced with 2/3 full or when
the “full” level is reached on the container.
31. Sharps containers are either wall mounted or otherwise
stabilized so they won’t tip over. They are located in areas
that allow for easy disposal while assuring access is restricted
in pediatric and behavioral health settings.
32. Sharps safety devices are used where possible and activated
immediately after use and prior to disposal.
Manner of
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Satisfactory
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Satisfactory*
N/A
Comments
4/20/2011
References:
 CDC Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2007, Standard Precautions.
 CDC Safe Injection Practices to Prevention Transmission of Infectious Agents to Patients, 2009.
 APIC Safe Injection, Infusion and Medication Vial Practices in Healthcare, July 30, 2009.
 CMS Infection Control Surveyor Worksheet: Safe Injection Practices. 2010.
 One and Only Campaign, Safe Injection Practices Coalition, 2010.
 Multi-dose Vials, The Joint Commission, June 9, 2010.