Professional Documents
Culture Documents
Intensive Care Unit Suite P
Intensive Care Unit Suite P
Intensive Care Unit Suite P
Instructions: Observe patients with central lines in place. Observe each practice and record the observation. In the column on the
right, sum (across) the total number of “Yes” and the total number of observations (“Yes” + “No”). Sum all categories (down) for
overall performance.
Are all inactive ports capped according Yes Yes Yes Yes
6 to facility policy? No No No No
N/A N/A N/A N/A
Date:______________
Location/Unit:____________
Are the bag and tubing off of Yes Yes Yes Yes
4 the floor? No No No No
Date:______________
Location/Unit:____________
Summary of
Ventilator: Observation Categories Patient Patient Patient Patient Observations
1 2 3 4
Yes Total Observed
Date:______________
Location/Unit:____________
Are all handwashing supplies, such Yes Yes Yes Yes Yes
2 as soap and paper towels, available? No No No No No
Are alcohol dispensers filled and Yes Yes Yes Yes Yes
7 working properly? No No No No No
Date:______________
Location/Unit:____________
Date:______________
Location/Unit:____________
Summary of Observations
Room Room Room
Isolation room: Observation Categories 1 2 3 Total
Yes
“Yes”& “No”
Yes Yes Yes
1 Is an isolation sign at the patient’s door? No No No
3 Are cover gowns available near each patient room Yes Yes Yes
or treatment area? No No No
Is other PPE for standard precautions (e.g., eye Yes Yes Yes
4 protection, face masks) available near each patient No No No
room or treatment area? N/A N/A N/A
Date:______________
Location/Unit:____________
(PAPR), available?
Are respirators stored outside the room or in an Yes Yes Yes
5 anteroom? No No No
Date:______________
Location/Unit:____________
Are hampers for soiled laundry Yes Yes Yes Yes Yes
4 labeled or color-coded? No No No No No
within a cabinet?
Date:______________
Location/Unit:____________
Is the medication preparation area free of opened single dose vials or opened
2 single use containers?
Yes No
If open multi-dose vials are present, are they dated and within the Beyond Use
3 Date (BUD) and the manufacturer’s expiration period?
Yes No N/A
Medications are prepared in a clean area free from contamination or contact with
4 blood, body fluids, or contaminated equipment.
Yes No
Are splash guards installed at sinks that are located close to medication prep
5 areas?
Yes No
7 Are hand washing supplies, such as soap, and paper towels, available? Yes No
8 Are alcohol dispensers readily available, filled, and functioning properly? Yes No
Date:______________
Location/Unit:____________
Summary of
Cart Cart Cart Observations
Medication cart: Observation Categories
1 2 3 Total
Yes
“Yes” + “No”
Yes Yes Yes
If multi-dose injectable medications are present are they
1 maintained in a dedicated medication prep space?
No
N/A
No
N/A
No
N/A
2 Are alcohol dispensers readily accessible, filled, and Yes Yes Yes
functioning properly? No No No
If open multi-dose vials are present, are they dated and Yes Yes Yes
4 within the Beyond Use Date (BUD) and the manufacturer’s No No No
expiration period? N/A N/A N/A
Date:______________
Location/Unit:____________
Instructions: Observe visitor area. Observe each practice below and answer Yes, No, or N/A. Sum all Yes and No responses. Divide by sum of “Yes” + ”No”.
Is there visible signage that clearly states that if visitors are ill,
3 they should report to the healthcare team? Yes No N/A
Is there visible signage that clearly states what, if any, visitor (children or
4 otherwise) restrictions are in place? Yes No N/A
Date:______________
Location/Unit:____________