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 / Manner of Confirmation / Satisfactory / Not Satisfactory* / N/A / Comments /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. / q Observation
q Interview
q Both
2. Disposable gloves are worn according to HealthEast policy/procedure. / q Observation
q Interview
q Both
3. Medications and supplies are stored and prepared in a clean area on a clean surface. / q Observation
q Interview
q Both
4. Needles and syringes are stored in their original packaging/wrapper. They are not stored unwrapped as sterility cannot be assured. / q Observation
q Interview
q Both
5. Skin at the injection/insertion site is prepared with the appropriate antiseptic which is allowed to dry on the skin. / q Observation
q Interview
q Both
6. The injection site is not touched after skin antisepsis has been done. / q Observation
q Interview
q Both
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. / q Observation
q Interview
q Both
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. / q Observation
q Interview
q Both
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. / q Observation
q Interview
q Both
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. / q Observation
q Interview
q Both
11. Medications are not prepared in one syringe and then transferred to another syringe. / q Observation
q Interview
q Both
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. / q Observation
q Interview
q Both
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. / q Observation
q Interview
q Both
14. The rubber septum/diaphragm of medication vials is always cleansed using friction with alcohol prior to each entry. / q Observation
q Interview
q Both
15. Multi-dose vials are dated when first opened and discarded within 28 days of opening or according to manufacturer’s recommendations. / q Observation
q Interview
q Both
16. Left over parenteral medications are never pooled or combined for later use. / q Observation
q Interview
q Both
17. Needles and cannulas are never left inserted in any vial rubber septum for multiple withdrawals. / q Observation
q Interview
q Both
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. / q Observation
q Interview
q Both
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) / q Observation
q Interview
q Both
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. / q Observation
q Interview
q Both
IV SOLUTIONS
21. Bags/bottles of IV solutions are never used as common source supply (i.e. flush solutions) for more than one patient. / q Observation
q Interview
q Both
22. Infusion supplies such as needles, syringes, flush solutions, administration sets, IV fluids are never used for more than one patient. / q Observation
q Interview
q Both
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. / q Observation
q Interview
q Both
BLOOD GLUCOSE MONITORING
24. Restrict use of finger stick capillary blood sampling devices to individual patients. / q Observation
q Interview
q Both
25. Use single-use lancets that permanently retract upon puncture. Never reuse finger stick devices and lancets. / q Observation
q Interview
q Both
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. / q Observation
q Interview
q Both
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. / q Observation
q Interview
q Both
SHARPS SAFETY
28. Needles/sharps are disposed of at the point of use. Containers are located conveniently in areas where sharps are used. / q Observation
q Interview
q Both
29. Sharps disposal containers are leak-proof, puncture-resistant and are red/orange in color or labeled with a biohazard label. / q Observation
q Interview
q Both
30. Sharps containers are emptied/replaced with 2/3 full or when the “full” level is reached on the container. / q Observation
q Interview
q Both
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. / q Observation
q Interview
q Both
32. Sharps safety devices are used where possible and activated immediately after use and prior to disposal. / q Observation
q Interview
q Both
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.