Accreditation

Sample questions for an infection control mock tracer

Accreditation Connection, October 3, 2005

Some or all of the questions below should be asked of infection control staff when running through a mock tracer, according to Joan Brake, RN, CPHQ, corporate director of performance improvement for Hospital Partners of America, the parent company of three hospitals in Houston and Austin, TX, and Redding, CA.

The questions are as follows:

  • Have we enforced the CDC's new hand hygiene guidelines regarding the use of alcohol-based hand rubs?
  • Do any of our direct-contact care providers have artificial nails?
  • Are natural nails longer than what the CDC guidelines recommend?
  • How effective is the use of personal protective equipment?
  • Do we communicate lab results with appropriate adjustments in medication?
  • Is the medication regimen appropriate for the identified organism?
  • Are the sterilizing flashing levels appropriate?
  • In general, how clean is the work environment?
  • How do we store clean and dirty items?
  • Do we cover the linen carts?
  • Is there appropriate storage under the sinks?
  • Have staff disposed of safety sharps and needles properly?
  • Have staff disposed of hazardous waste safely?
  • Have staff labeled red bags and sharps containers properly?
  • Have staff tested negative-pressure rooms often enough?
  • How do we handle a needlestick injury or bloodborne exposure?
  • Can staff easily locate their IC manual and departmental IC policies?

Adapted from the September issue of Briefings on Hospital Safety.

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