"Injection Safety Adherence Monitoring Tool" - California

Injection Safety Adherence Monitoring Tool is a legal document that was released by the California Department of Public Health - a government authority operating within California.

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Assessment completed by:
Healthcare-Associated Infections Program Adh erence Monitoring
Date:
Safe Injection Practices
Unit:
Regular monitoring with feedback and staff education is recommended to improve safe injection practices. Use this tool to identify gaps and
opportunities for improvement. Monitoring may occur in any type of patient care location where medication is prepared or provided to patients.
Instructions: This form can be used to observe up to 4 areas where providers are preparing or providing patient medications, or 4 observation
opportunities for each practice type. Observe each practice and check a box if adherent, Yes or No. In the column on the right, record the total number of
“Yes” for adherent practices observed and the total number of observations (“Yes” + “No”). Calculate adherence percentage in the last row.
Adherence
Area 1 or
Area 2 or
Area 3 or
Area 4 or
Safe Injection Practices
Opportunity 1
Opportunity 2
Opportunity 3
Opportunity 4
# Yes
# Observed
Proper hand hygiene is performed prior to preparing and administering
SI1.
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
medication.
Medication preparation area is clean and free from contact with blood,
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
SI2.
body fluids, or contaminated equipment.
Needles and syringes are used for only one patient. This includes
SI3.
manufactured prefilled syringes and cartridge devices such as insulin
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
pens.
The rubber septum on a medication vial is disinfected with alcohol
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
SI4.
prior to piercing.
The medication vial is entered with a new needle and a new syringe,
SI5.
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
even when obtaining additional doses for the same patient.
Single-dose or single-use medication vials, ampules, and bags or
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
SI6.
bottles of intravenous solution are used for only one patient.
Medication administration tubing and connectors are used for only
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
SI7.
one patient.
Multi-dose vials are dated by the healthcare worker when first opened,
and discarded within 28 days unless manufacturer specifies a different
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
SI8.
date for that opened vial.
Note: This is different from the expiration date printed on the vial.
Multi-dose vials are dedicated to individual patients whenever
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
SI9.
possible.
For more information on Safe Injection Practices visit: www.oneandonlycampaign.org
Version 2016.09.02
Assessment completed by:
Healthcare-Associated Infections Program Adh erence Monitoring
Date:
Safe Injection Practices
Unit:
Regular monitoring with feedback and staff education is recommended to improve safe injection practices. Use this tool to identify gaps and
opportunities for improvement. Monitoring may occur in any type of patient care location where medication is prepared or provided to patients.
Instructions: This form can be used to observe up to 4 areas where providers are preparing or providing patient medications, or 4 observation
opportunities for each practice type. Observe each practice and check a box if adherent, Yes or No. In the column on the right, record the total number of
“Yes” for adherent practices observed and the total number of observations (“Yes” + “No”). Calculate adherence percentage in the last row.
Adherence
Area 1 or
Area 2 or
Area 3 or
Area 4 or
Safe Injection Practices
Opportunity 1
Opportunity 2
Opportunity 3
Opportunity 4
# Yes
# Observed
Proper hand hygiene is performed prior to preparing and administering
SI1.
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
medication.
Medication preparation area is clean and free from contact with blood,
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
SI2.
body fluids, or contaminated equipment.
Needles and syringes are used for only one patient. This includes
SI3.
manufactured prefilled syringes and cartridge devices such as insulin
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
pens.
The rubber septum on a medication vial is disinfected with alcohol
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
SI4.
prior to piercing.
The medication vial is entered with a new needle and a new syringe,
SI5.
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
even when obtaining additional doses for the same patient.
Single-dose or single-use medication vials, ampules, and bags or
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
SI6.
bottles of intravenous solution are used for only one patient.
Medication administration tubing and connectors are used for only
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
SI7.
one patient.
Multi-dose vials are dated by the healthcare worker when first opened,
and discarded within 28 days unless manufacturer specifies a different
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
SI8.
date for that opened vial.
Note: This is different from the expiration date printed on the vial.
Multi-dose vials are dedicated to individual patients whenever
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
SI9.
possible.
For more information on Safe Injection Practices visit: www.oneandonlycampaign.org
Version 2016.09.02
Healthcare-Associated Infections Program Adh erence Monitoring
Safe Injection Practices - continued
Adherence
Area 1 or
Area 2 or
Area 3 or
Area 4 or
Safe Injection Practices
Opportunity 1
Opportunity 2
Opportunity 3
Opportunity 4
# Yes
# Observed
Multi-dose vials to be used for more than one patient are kept in a
centralized medication area and do not enter the immediate patient
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
SI10.
treatment area (e.g. operating room, patient room/cubicle)
Note: If multi-dose vials enter the immediate patient treatment area, they
should be dedicated for single-patient use and discarded immediately after use.
All sharps are disposed of in a puncture-resistant sharps
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
SI11.
container.
Filled sharps containers are disposed of in accordance with
SI12.
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
state regulated medical waste rules.
All controlled substances (e.g., Schedule II, III, IV, V drugs) are
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
SI13.
kept locked within a secure area.
Healthcare personnel wear a facemask (e.g. surgical mask)
when placing a catheter or injecting material into the epidural
SI14.
or subdural space (e.g. during myelogram, epidural or spinal
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
anesthesia).
# of Correct Practice Observed (“# Yes”): _______
Adherence _______%
Total # of Observations (
# Observed
): _______
(“# Yes” ÷ Total “# Observed” x 100)
(Up to 56 total)
If practice could not be observed (i.e. cell is blank), do not count in total # Observed.
For more information on Safe Injection Practices visit: www.oneandonlycampaign.org
Version 2016.10.12
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