Patient Safety Tool: Hand Hygiene and Glove Use Monitoring Form

The Institute for Healthcare Improvement, in collaboration with the CDC, the Association for Professionals in Infection Control and Epidemiology and the Society of Healthcare Epidemiology of America, prepared the “How-to Guide: Improving Hand Hygiene — A Guide for Improving Practices among Health Care Workers.” Included in this guide is a hand hygiene and glove use monitoring form.

The first page of this tool is the form itself, which provides rows for documentation of 30 encounters between a member of an organization and a patient; the second page is a list of instructions. In the instructions, IHI says each row in the form should be used to record an encounter between one healthcare worker and one patient that involves touching by the worker of the patient or the patient’s immediate environment.

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Download the hand hygiene and glove use monitoring form (pdf) for adaptation and use in your facility.

Source: Institute for Healthcare Improvement

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