Infection Control Checklist - ASHP

1 1 CHAPTER 9 Infection Control ChecklistThe Joint Commission, in its prevention and Control ofinfection (IC) standards, requires organizations to takeprecautions to reduce the risk of acquiring and transmit-ting infections . Organizations must have effective, orga-nization-wide IC programs. All departments and servicesmust participate in the organization s IC : Organizations surveyed under the Comprehen-sive Accreditation Manual for Hospitals: The Offi-cial Handbook (CAMH) must comply with the IC stan-dards that are applicable to them.

2 Organizations sur-veyed under other Joint Commission accreditationmanual(s) should review the appropriate manual. (SeeChapter 1.) Checklist OrganizationThis chapter presents Infection Control precautions forhealth care personnel in a Checklist format. They are con-sistent with The Joint Commission s IC standards,1 cur-rent Centers for Disease Control and Prevention (CDC)hand-hygiene guidelines2 (see NPSG 7 in Chapter 6), andthe provisions of the United States Pharmacopeia (USP)Chapter <797>.3 (See Chapter 19.)

3 Note: Although this Checklist does not address theseprecautions completely, it should help to reduce therisk of acquiring and transmitting infections . Healthcare organizations should check for new and updatedstandards on The Joint Commission s Web site, andfor new and updated hand-hygiene guidelines on theCDC s Web site. (See Appendix.) Pharmacies shouldcontact their board of pharmacy and other state agen-cies to determine how their state integrates USP<797> provisions into its notes are compliance expectations and suggestionsthat are based on the authors personal experiences, reportsfrom surveyed organizations, and surveyors notes reflect legal requirements, previous Joint Com-mission standards, or commonly accepted standards of prac-tice.

4 Others note variations in interpretation of the notes are referenced to the Symbols Special attention should be paid toEPs preceded by an icon. The Checklist uses a icon be-fore an EP if documentation is required, and an ! iconbefore an EP if noncompliance is likely to create an im-mediate risk to patient safety or to the quality of care pro-vided. An ; icon before an EP indicates that a Measureof Success (MOS) is required if the EP is scored non-com-pliant during a Usage SuggestionsTo assess compliance, use the Checklist and proceed sys-tematically.

5 Mark the item Yes if you are currently com-pliant and are sure you will continue to be compliant. Markthe item No if you are currently not compliant (even ifyou are sure you will be compliant later). If you are notsure of your answer, leave a blank response. A few itemsmay be not applicable ( NA ). Answer honestly, use a pen-cil (so you can change your answers), and make notes onthe pages ( , reasons for noncompliance and locationof documents). Concentrate your efforts on resolving all No and blank Continuous Compliance with Joint Commission Standards: A Pharmacy GuideYes No NAYes No NAChecklistInfection Risk IdentificationAccidents, incidents, unsafe practices, and unsanitary conditions that pose a risk ofinfection for patients, visitors, and staff are Risk ReportingAccidents, incidents, unsafe practices, and unsanitary conditions that pose a risk ofinfection for patients, visitors, and staff are.

6 Infection Control related incidents are usually reported to the InfectionControl Committee or a designated individual. The organization s Infection con-trol plan should contain specific information on how to submit these Control SurveillanceEach department or service participates in Infection Control surveillance activitiesas required by the and DisinfectingThe pharmacy and areas where medications are stored, compounded, dispensed, pre-pared, and administered are uses organization approved cleaning procedures and cleaning and are an adequate number of sinks and sufficient space and materials for clean-ing equipment and washing : Cleaning should be coordinated with housekeeping personnel, and clean-ing agents and procedures approved by the Infection Control Committee mustbe used.

7 Particular attention must be given to prepackaging, compounding, andsterile preparation areas as well as areas likely to harbor microorganisms thatcould contaminate medications or transmit disease to hand rub containers are appropriately agents and supplies are available to and disinfecting agents are appropriately and disinfecting agents are appropriately is kept clean and stored in a clean : Areas under sinks are not clean areas. Mortars, pestles, glassware, andother equipment that must be kept clean must be stored in a clean 9.

8 Infection Control ChecklistYes No NADrug preparation, packaging, and dispensing devices ( , mortars, pestles, pill crush-ers, pill splitters, counting trays, graduated cylinders, unit-dose packaging devices,and balances) are cleaned after each use and disinfected if used for crushing or splitting tablets are cleaned immediately after useaccording to manufacturers recommendations and carts, drawers, and bins containing individual patient s medications arekept dispensing cabinets and bins are cleaned according to the manufacturer srecommendations and : Many organizations develop a schedule for cleaning equipment and boxes are stored off the : This is not specifically required by the standards.

9 However, some organi-zations and surveyors insist that they be stored off the containers are not stored or opened ( , torn or cut) in any area reservedfor prepackaging medications or compounding sterile : Handling and storing shipping containers ( , cardboard boxes) must bedone with minimal air disturbances and dissemination of dust particles. Intrave-nous (IV) bags and bottles and related supplies must be removed from cartonsand wiped with an approved disinfecting agent prior to placing them in the ster-ile preparation disposes of waste in accordance with the organization s Infection Control poli-cies and does not create a nuisance or a breeding place for insects, rodents, and ver-min or otherwise permit the transmission of disposal containers are close to the area of waste is not mixed with infectious.

10 Check the organization s policies on disposal of noninfectious waste andinfectious WasteStaff disposes of infectious waste in accordance with the organization s infectioncontrol policies and waste does not create a nuisance or a breeding place for insects, rodents,and vermin or otherwise permit the transmission of Continuous Compliance with Joint Commission Standards: A Pharmacy GuideYes No NAInfectious waste disposal containers are close to the area of waste is placed in specially marked containers ( , red bags) and dis-posed of separately from routine.