Patient Safety & Infection Control Rounding Report Card
Nurse Assigned to the Patient:________________________________
Room #________________
N/A Correct
Reviewed with nurse:
Pumps
Assessed line with pt. disconnected
Correct Patient Profile/Library
Correct Location/Pt. ID (found on yellow card)
IV sets loaded properly
IVs infusing in guardrails or maintenance mode: _______________
Missing Additive
Medications infusing via guardrails:___________________
Medication Hanging
All lines labeled with change date (Except ER)
Disconnected lines found with sterile cap on the end
SCORE:____________________ (See Back for Scoring Grids & Details)
IV found infusing without a pump, solution and/or medication hanging:
_____________________________________________________________
Central Lines
Dressing Dry and intact
No visible blood in lumens or caps
3/3= 100%
2/3 = 66%
1/3= 33%
No add on devices that are not being used
SCORE:______________________
Revised 01/29/2013
0/3= 
Scoring System for Alaris Pump Rounding
7/7 = 100%
6/7 = 85%
5/7 = 71%
4/7 = 57%
3/7 = 42%
2/7 = 28%
1/7 = 14%
6/6 = 100%
5/6 = 83%
4/6 = 67%
3/6 = 50%
2/6 = 33%
1/6 = 17%
5/5 = 100%
4/5 = 80%
3/5 = 60%
2/5 = 40%
1/5 = 20%
4/4 = 100%
3/4 = 75%
2/4 = 50%
1/4 = 25%
Patient Profile or Library: Specific to the patient location and/or medication
infusing. Example a cancer patient on the 4th floor would be in the oncology
library. An ortho patient on the 4th floor would be in med-surg library
Correct Patient ID: Found on the yellow card and specific to unit location
IV’s: Should always be in maintenance mode if it is a standard fluid like NS. If
there is an additive in the solution, that should be selected. Example if the
solution has 10 meq of KCL it scrolls across the screen. This is true for blood
and blood products as well. Basic mode should not be needed unless it is an
emergent situation if the programming of the pump is correct.
Medications: All medications should be selected and programmed into the
pump. There is no excuse! If the medication cannot be found the policy
states to notify pharmacy through the IVpumpmedreqiest@nwhsea.org email address. Problems cannot be fixed if not reported and the pumps are
routinely updated. If the medication is in the library, and you missed it,
pharmacy will reply to your e-mail and let you know where to find it.
If a pump is missing a yellow card and programming cheat sheet please
notify biomed so they can get one to you
Revised 01/29/2013