Different members of the Brainerd Lakes Surgery Center staff perform the review every quarter to increase their recognition of what needs to be done, according to Ms. Berreth.
To download a copy of this form, click here (doc).
Infection Control Environmental Review
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GENERAL: Quarterly review [Month] |
Adequate |
Needs improvement |
Comments |
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Handwashing between patients, after patient contact, after glove removal, after personal breaks |
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Proper handwash technique; wet hands first, 10 second scrub, rinse, turn off faucet with paper towel |
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Soap dispensers are full and functional |
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General appearance of area is clean, uncluttered |
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Inspect patient rooms and bathrooms for inappropriate supplies or outdated supplies |
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Open bottles of fluids discarded every 24 hours/7 am (saline for irrigation) |
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Single use medication vials discarded (sterile saline, bacteriostatic water) |
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Multi-use medication vials discarded according to manufacturer outdate (exception: insulin, certain RC products) |
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IV tubing labeled with date |
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Urine drainage bags off floor |
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Linen carts covered – Linen carts in clean utility with other supplies need to be covered or behind closed cabinet |
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No shaking, agitation of linens |
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Refrigerator temperature logs for patient use refrigerators – monitored and recorded daily ( approp. action taken if necessary) |
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Only patient items in patient refrigerators |
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No patient care items under/on sinks (including cups, paper towels, anything that may get wet) |
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No wet areas under ice machines |
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No stuffed animals in toy rooms |
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Hampers used appropriately – ie. No bags on floors, no overflowing of linen |
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Ceiling tiles clean and dry |
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At least 18″ clearance below sprinkler heads |
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Check biological monitoring logs for completeness, consistency |
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OSHA BLOODBORNE PATHOGEN STANDARD |
Adequate |
Needs improvement |
Comments |
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Staff following Universal/Standard Precautions |
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No food, beverages in work area |
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No applying cosmetics, lip balm in work area |
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No recapping of needles after use (single handed technique acceptable) |
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Maximum fill level of needle boxes as indicated on container |
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Personal Protective Equipment available (PPE) |
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Proper use of PPE: -gloves when handling body fluids -gowns when anticipated exposure to clothing -masks/face shields when anticipated exposure |
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Removal of PPE prior to leaving patient room |
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Glove boxes filled |
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Proper clean up of blood spills (spray with bleach [Dispatch], allow contact time of 1-2 minutes, then wipe) |
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Pick up broken glass with tongs |
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Proper reporting of exposures (report immediately, complete event report, report to ETD) |
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Utilizes safety devices as available |
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CLEAN UTILITY |
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Clean items only |
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No medical supplies on floor |
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No medical supplies left in original shipping container |
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Nothing stored under sinks |
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Check for outdated supplies |
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Door closed |
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DIRTY UTILITY |
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Dirty items only |
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Door closed on soiled utility room |
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No mini drinking cups, tissues, paper towels, toilet tissue |
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No hoses touching in floor drains |
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PPE available |
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HANDLING OF SPECIMENS |
Adequate |
Needs improvement |
Comments |
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PPE utilized when handling specimens |
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Assure covers are properly secured prior to placement in CTS carrier |
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HANDLING OF INFECTIOUS/ HAZARDOUS WASTE |
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Properly identifies examples of hazardous waste |
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Contaminated waste labeled (red bag) |
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Needles/Sharps disposed properly |
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Utilizes safety devices as available |
Source: Sandy Berreth, Brainerd Lakes Surgery Center. Adapted and reprinted with permission.
