World Health Patient Safety SAVE LIVES

Organization AWorld Alancs for Sater Health Care Clean Your Hands

Observation Form
Session
Facility: TMC Period Number:
Number:
Date: Observer:
Service:
Cancey Sp. (dd/mmlyy) 12/ 2l (initlals)
Start/End time:
Ward:
a PI (hh:.mm)
Page N:

Session duration:
Department: (mm)
City*:

Country
Prof.cat NUrse Prof.cat NUrse Prof.cat Doctor Prof.cat HCA /HK
Code Code Code Code
N N° N N
HH Action Opp. Indication HH Action Opp. IndicationHH Action Opp. Indication HH Action
Opp. Indication
bef-pat. HR bef-pat HR bef-pat
1 bef-aseptHW AR 1
bef-pat.
bef-asept.
HR
HW
bef-aseptHW
aft-b.f.
O missed
bef-aseptHW
aft-b.f. O missed
t-b.f.
O missed aft-b.f. missed
aft-pat. gloves
aft-pat. O gloves -pat. O gloves aft-pat. gloves
aftp.sur. aft.p.sur. aft p.surr. aft.p.surr.
bef-pat. HR bef-pat. bef-pat HR bef-pat. HR
bef-asept HR 2 bef-asept.HW
2
bef-asep HW
aft-b.f. aft-b.f.
W bef-aseptHW
aft-b.f. aft-b.f. O missed
missed
aft-pat.
O missed
aft-pat. missed aft-pat.
aft-pat O gloves gloves Ogloves Vloves
aft.p.surr. aft.p.sur. aft.p.surr aft.p.sur
bef-pat. bef-pat. bef-pat. AR bef-pat. HR
HR 3 bef-aseptHW 3 bef-asept. 3 bef-asept. HW
bef-asept HW
aft-b.f. aft-b.f. O missed aft-b.f.
HW
O mjssed aft-b.f. missed
O missed aft-pat.
aft-pat. Vgloves
aft-pat. O gloves aft-pat. Vgloves O gloves
J aft.p.surr. aft.p.surr. aftp.surr Vaftp.surr.
bef-pat 0HR bef-pat. | HR bef-pat. HR bef-pat. HR
bef-asept. HW 4 bef-aseptHW bef-asept HW bef-asept HW
aft-b.f. aft-b.f. aft-b.f. O missed aft-b.f. O missed
O missed missed aft-pat. aft-pat.
aft-pat. gioves
aft-pat. gloves Sgloves O gloves
aft p.sur. aft p.sur. aft p.sur. aft.p.sur.
oef-pat. oef-pat bef-pat bef-pat. HR
HR 5 bef-asept.HR 5 bef-asept. HR 5
bef-asept.
bef-asept H aft-b.f. aft-b.f.
HW aft-b.f.
| Hw
aft-b.f. Omissed O missed O missed O missed
aft-pat. O gloves
aft-pat. O gloves
aft-pat. gloves
aft-pat. Ogioves
aft.p.surr. aft.p.surr. aft.p.sur. aftp.sur.
bef-pat. bef-pat. bef-pat bef-pat.
HR
bef-asept HR
bef-asept HR
bef-aseptHW
bef-asept.HR

HW bef-asept HW
aft-b.f. aft-b.f. Oaft-b.f. OHW
aft-b.f. O missed missed nissed missed
at-pat. O gioves aft-pat. gloves
aft-pat. gioves
aft-pat. gloves
Uaftp.surr. aftp.sur. aft p.surr. aft.p.surr.
bef-pat. HR bef-pat bef-pat.
bef-pat. HR bef-asept HW bef-asept. HW
HR
bef-asept. HW
HR
bef-asepr HW aft-b.f. aft-b.f. aft-b.f. missed
aft-b.f. missed missed | aft-pat. missed aft-pat.
aft-pat. aft-pat. gloves gloves O gloves
aftp.surT.
gloves
aft.p.sur. aftp.surr. aftp.sur
bef-pat. bef-pat. HR bef-pat. bef-pat.
AR bef-asept HW
8 bef-asept.HR
8 bef-aseptHW
aft-b.f.
bef-aseptHW
aft-b.f. O missed
aft--b.f
missed aft-b.f. O missed
O missed aft-pat. aft-pat.
aft-pat. gloves
aft-pat O gloves O gloves
aft.p.sur.
gloves
aft.p.sur. aft.p.surr. aftp.surr
To be completed by the data manager.
* Optional, to be used if appropriate, according to the localto needstheand regulations. distrbuted without waranty
document However the published material is being
All reasoneble precautions have been taken by the World Health
irdormation
Organization verify containednein this be iacle tor damages arsing
ith reader In no event shsil the Norid Heaith oraanizaion
tor tne Interpretaton ano use ar tnemateral nes
Ofany xind etner exDressed orimplied. ihe responsioifity this material
infection Control Programme for their acbve participation n developing
Geneve (HUG). in particular the members of the
WHO acknowledges the Hopitaux Universitaires.de
Revised August 200
 World Health Patient Safety SAVE LIVES
Organization AWornd Allance for Sater Health Care Clean Your Hands

Observation Form
Facility: Period Number: Session
Number:
Service: Date: Observer:
(ddmmly) /12/2 (initials)
Ward: Start/End time:
Go PI (hh:mm) : Page N:
Department: Session duration:
(mm) City:
Country:
Prof.cat Doctor
Code Prof.cat HCA/HK Prof.cat Prof.cat
N° Code Code Code
N°
Opp. Indication HH Action Opp.
N N
bef-pat. Indication HH Action Opp. Indication HH Action Opp. Indication HH Action
bef-asept
bef-asept. HR
HW bef-pat. bef-pat. bef-pat.
bef-aseptHR ] HR
aft-b.f. missed aft-b.f. UHW bef-asept HW bef-asept. HR
HW
aft-pat. Ogloves aft-pat. missedd aft-b.f.
O missed aft-b.f. O missed
Uaftp.sur. Uaft.p.surr. O gloves aft-pat.
gloves aft-pat.
aft.p.sur glovesS
bef-pat aftp.surr
2 bef-asept.HR
HW
2 bef-pat HR
bef-aseptHW bef-pat. | HR bef-pat.
aft-b.f.
aft-pat. O missed
O gloves
aft-b.f.
aft-pat. O missed bef-aseptHW
aft-b.f. O missed
2 bef-asept.
aft-b.f.
HR
| HW
aft p.sur. aft-pat. aft-pat. O missed
Uaftp.sur. O gloves aftp.surr. gloves
aft p.sur O gloves

3 bef-pat.
bef-asept.HR bef-pat.
3 bef-asept HRHW
3 bef-pat.
bef-asept HR
HW bef-pat. ] HR
aft-b.f. 3 bef-asept.
aft-pat. missed aft-b.f. O missed aft-b.f. aft-b.f. | HW
aft p.sur. gloves aft-pat. O gloves aft-pat.
O missed O missed
aft.p.sur aft.p.surr. Ogloves aft-pat. gloves
bef-pat. aftp.sur
bef-asept.HR 4
bef-pat.
bef-asept HR
HW bef-pat HR bef-pat.
aft-b.f. UHW 4 Def-asept.YHR
HR
aft-pat. missed aft-b.f. missed
aft-b.f. HW
O missed
bef-asept.
aft-b.f.
HWN
aft.p.sur. gloves
aft-pat. aft-pat. O missed
aftp.surr. Ogloves Ogloves aft-pat.
aft.p.surr. aft.p.surr. gloves
bef-pat. 6ef-pat.
5 bef-asept HR
HW
bef-asept HW
bef-aseptHR 5 bef-pat. HR bef-pat.
aft-b.f.
missed aft-b.f. bef-asept.HW
aft-b.f. bef-asept HR
HW
aft-pat. Omissed O missed aft-b.f.
O gloves aft-pat. Ogloves aft pat. aft-pat. O missed
aft.p.surr aft.p.surr. aft.p.surr. gloves
Ogloves
aftp.sur.
bef-pat. bef-pat. HR bef-pat.
6
bef-asept ] HR
HW bef-asept HWN bef-asept.
| HR
| HW
bef-pat.
6 bef-asept.HW HR
aft-b.f. aft-b.f. aft-b.f. aft-b.f.
aft-pat. missed
O gloves aft-pat.
O missed
gloves aft-pat.
O missed
O gloves aft-pat
O missedd
aft p.surr. aft.p.surr. aft.p.sur. aft.p.surr. gloves

bef-pat. ] HR bef-pat. bef-pat. bef-pat.

bef-asept. UHW bef-asept. HR 7 b
bef-aseptHW
ef-aseptHR 7
bef-asept ] HR
HW
aft-b.f. aft-b.f. HW aft-b.f. aft-b.f.
ft-pat. missed Ogloves aft-pat.
missed
O gloves
aft-pat. O missed
O gloves aft-pat.
O missed
gloves
aftp.sur. aft.p.surr. aft.p.sur. aft.p.sur
bef-pat. HR bef-pat. bef-pat. bef-pat. HR
8
bef-asept H bef-asept HW 8 bef-aseptHW
bef-asept. HW
aft-b.f. nissed aft-b.f. missed aft-b.f. O missed
aft-b.f.
O missed
aft-pat.
Ogloves aft pat. O gloves aft-pat. O gloves aft-pat. O gioves
aft.p.surr. aft.p.surr. aft p.surr. aftp.sur
To be completed bythe data manager.
** Optional,to be used if appropriate,according to the local needs and regulations.
resonable precautons have beentaken bytheWord Healith Organization to venfy he information containedinthisdocument Howaver thepubished maenals bein detibuedhotrnby
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