INFECTION PREVENTION AND CONTROL TOOL FOR
PHARMACIES UNDERTAKING FLU VACCINE
ADMINISTRATION
Requirement:- Systems are established to ensure appropriate infection prevention and
control procedures are in place
EVIDENCE
There is an infection prevention and control policy in place which includes:1. Procedures
2. Staff training for: Hand washing
 Sharps management
 Waste management
 Decontamination
The pharmacy will participate in an Infection Prevention and Control Audit. It is
expected that contractors will be working towards achieving all standards and must
demonstrate progress with any actions identified.
Contents
Page
Hand Hygiene
2
Environment
4
Disposal of Waste
6
Spillage and/or Contamination with Blood/Body Fluids
7
Personal Protective Equipment
8
Prevention of Blood/Body Fluid Sharps Injuries, Bites and Splashes
9
Safe Storage of Vaccines
11
Decontamination
12
1
Hand Hygiene
Standard Statement: Hands will be decontaminated correctly and in a timely manner
using a cleansing agent to reduce risk of cross infection
Yes No N/A Comments
1 The Practice has procedures in place and
a policy for Hand Hygiene
2 Systems are in place to ensure
distribution, compliance and monitoring
of the hand hygiene policy and
procedures
3 Hand hygiene is an integral part of
Induction for all staff
4 Staff have received training in hand
hygiene procedures.
5 Staff involved in clinical procedures
should have short, clean nails free from
nail extensions and varnish
6 No wrist watches, stoned rings or other
wrist jewellery are worn during clinical
procedures
7 Hand hygiene within the pharmacy is
encouraged
8 Posters promoting hand hygiene are
available and are on display
9 There is a hand wash basin in each
Consulting room where the procedure is
undertaken
10 Hand washing facilities are clean and
intact (check sinks taps, splash backs,
soap and towel dispensers)
11 There is easy access to the hand wash
basin
12 For new premises and refurbishments
since April 2004 it is compulsory that the
hand washbasin has no plugs, no
overflows, water from taps not directly
situated above plughole.
13 For older and non-refurbished buildings
compliance with the above is a
recommendation for all other premises
(since April 2004).
14 Elbow operated taps are available at all
hand wash basins in clinical areas
15 Liquid soap is available at each hand
wash basin
16 Liquid soap is in the form of single use
cartridge dispensers
2
17 There is no bar soap at hand washing
basins in treatment/clinical areas
18 Alcohol hand rub is available at the point
of care as per local and national
standards
19 Clinical staff are encouraged to use hand
moisturisers that are pump operated or
personal use
20 Soft absorbent paper towels are available
at all hand wash sinks
21 There are no re-usable cotton towels
used to dry hands
22 There are no re-usable nailbrushes used
or present at clinical hand wash sinks
23 There is a foot operated bin for waste
towels in close proximity to hand wash
sinks which are fully operational
Additional Comments:
3
Environment
Standard: The environment will be maintained appropriately to reduce the risk of
cross infection
Yes No N/A Comments
1 The Practice has access to: NHS Sheffield document
Community Pharmacies Room
Specification for Local Enhanced
Services1,
 Revised guidance for Contract
Cleaning2,
 NHS Healthcare Facilities
Cleaning Manual 20093
 National Specifications for
Cleanliness4
2 The organisation has developed or is in
the processes of developing procedures
on cleaning (including a cleaning
schedule)
3 The Practice has processes in place to
identify and rectify cleaning
problems/issues
4 Overall appearance of the environment is
tidy and uncluttered with only
appropriate, clean and well maintained
furniture used
5 Fabric of the environment and equipment
smells clean, fresh and pleasant
6 The allocation of rooms for the
administration of vaccines is fit for
purpose
 Rooms where clinical practice
takes place are not carpeted
 Floor coverings are washable and
impervious to moisture and are
sealed regularly
 The complete floor, including
edges and corners are visibly
clean with no visible body
substances, dust, dirt or debris
 Furniture, fixtures and fittings
should be visibly clean with no
body substances, dust, dirt or
debris or adhesive tape
1
http://www.sheffield.nhs.uk/infectioncontrol/resources/commphamracyroomspecles.pdf
2
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4097532
http://www.nrls.npsa.nhs.uk/resources/?EntryId45=61830
4
http://www.nrls.npsa.nhs.uk/resources/?EntryId45=59818
3
4
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All dispensers, holders and all
parts of the surfaces of dispensers
of soap and alcohol gels, paper
towel/couch roll/toilet paper
holders are visibly clean with no
body substances, dust, dirt or
debris or adhesive tape
There is a procedure in place for
regular decontamination of
curtains and blinds where windows
are present
Furniture in patient areas e.g.
chairs and couches are made of
impermeable and washable
materials
Chairs are free from rips and tears
Furniture that cannot be cleaned is
condemned in clinical practice
areas
Tables are tidy and uncluttered to
enable effective cleaning
Medical equipment is cleaned,
maintained and stored
appropriately
Additional Comments:
5
Disposal of Waste
Standard Statement: Waste is disposed of safely without risk of contamination or
injury and in accordance with legislation.
Yes No N/A Comments
1 The Practice has procedures/policy for
the disposal of waste
2 Systems are in place to ensure
distribution, compliance and monitoring
of waste procedures
3 There is evidence that the waste
contractor is registered with a valid
licence (check records)
4 If generating clinical waste the pharmacy
is registered to do so
5 Clinical waste is disposed of and
transported in UN approved appropriate
sharps containers
6 All other waste is classified as Domestic
waste and is disposed of in domestic
waste bags
7 Staff have received a briefing which
includes the correct and safe disposal of
clinical waste
8 There is evidence that staff are
segregating waste correctly
9 Staff are aware of the waste segregation
procedures
10 The waste storage area is clean and tidy
11 There is no storage of waste in corridors
or in other inappropriate areas
inside/outside the facility whilst waste is
awaiting collection
12 Hazardous and offensive waste is
segregated from other waste for
transportation
13 All waste bins used are foot operated,
lidded and in good working order
14 All waste bins are visibly clean –
externally and internally
15 All clinical waste containers are kept
secured and are inaccessible to the
public
16 The clinical waste containers are clean
Additional Comments:
6
Spillage and/or Contamination with Blood/Body Fluids
Standard Statement: Body Fluid spillage or contamination is dealt with in a way that
reduces the risk of cross infection.
Yes No N/A Comments
1 The pharmacy has comprehensive
procedures for dealing with body fluid
spillages
2 Systems are in place to ensure body fluid
spillage procedures are available to all
staff
3 Staff are aware of procedures for dealing
with body fluid spillages.
4 Staff who have previously come in
contact5 with spillages (blood and body
fluids) have been successfully
immunised against Hepatitis B
5 All equipment and the environment is
visibly clean with no body substances,
dust dirt or debris
6 Dedicated blood and body fluid spillage
kits6 are available for decontaminating
and cleaning body fluids and are in date.
7 Personal protective equipment is
available (as per spillage kit)
8 Equipment used to clear up body fluid
spillages is disposable or able to be
decontaminated (as per spillage kit)
9 Appropriate disinfectants are available for
cleaning all body fluid spillages, for
example Milton 2% at 1000ppm or
chlorclean
Additional Comments:
5
Green Book advises post exposure vaccination following contamination in eyes, mouth, fresh cuts &
abrasions (http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_079917)
6
E.g.Wallace Cameron Body Fluid Kit Piccolo Dispenser 1012045 available from NPA
7
Personal Protective Equipment
Standard Statement: Personal protective equipment is available and is used
appropriately to reduces the risk of cross infection
Yes No N/A Comments
1 The Practice has comprehensive
procedures/policy for the appropriate use
of personal protective equipment e.g.
gloves and aprons
2 Systems are in place to ensure that
personal protective equipment policy and
procedures are in use by all relevant staff
3 Non-sterile, latex free and powder free
gloves conforming to European
Community [EC] standards are fit for
purpose (no splitting etc) and are
available
4 Alternative gloves should be available if
assessed that the Pharmacist is
allergic/sensitised to the latex free
gloves.
5 Powdered or polythene gloves are not in
use
6 There is an appropriate range of sizes
available
7 Gloves are worn as single use items for
each clinical procedure or episode of
patient care
8 Hands are decontaminated following the
removal of gloves
9 Gloves are stored appropriately over floor
level
10 Disposable plastic aprons are worn when
there is a risk that clothing or uniform
may become exposed to body fluids or
become wet. Please see blood and body
fluid spillage kit.
11 Disposable plastic aprons are worn as
single-use items for each clinical
procedure or episode of patient care.
Please see spillage kit.
Additional Comments:
8
Prevention of Blood/Body Fluid Sharps Injuries, Bites and Splashes
Standard Statement: sharps/needlestick injuries, bites and splashes involving blood
or other body fluids are managed on a way that reduces the risk of injury or
infection.
Yes No
1
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5
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7
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9
10
11
12
13
14
N/A Comments
The pharmacy has comprehensive
procedures for the management of
sharps/needlestick injuries or splashes
and bites in a way that reduces injury or
infection
Systems are in place to ensure that the
procedures for the management of
sharps/needlestick injuries, bites and
splashes are available to all staff
Staff are aware of these procedures and
have signed to confirm they will be
complied with
Arrangements are in place to ensure that
the pharmacist and staff involved in
administering vaccines are immunised
against Hepatitis B
There are arrangements in place that
ensures staff are dealt with appropriately
in the event of a needlestick/sharp injury
or bite/splash
All needlestick/sharps/bites/splash
injuries are recorded
There is signage (e.g. a poster) displayed
for the management of
needlestick/sharps injuries and/or bites
and splashes
Sharps containers comply with BS 7320
(1990)/UN 3291
Sharps containers are correctly
assembled
All sharps containers in use are labelled
with date, pharmacy address and signed
Sharps containers are available at the
point of use
When full and ready for disposal all
sharps containers are dated and signed
Sharps containers are stored safely away
from the public and out of reach of
children
Sharps containers are not filled beyond
the indicator mark i.e. 2/3 full
9
15 Sharps bins are used for the disposal of
sharps only
16 Needles and syringes are discarded as a
single unit
17 Syringes with a residue of Prescription
Only Medication are disposed of
according to current legislation
18 The temporary closure mechanism is
used when the bin is not in use*
19 Full sharps containers are sealed only
with the integral lock – tape or stickers
are not used
20 Sealed and locked bins are stored in a
locked facility away from public access
21 Sharps containers are available for use
and located within easy reach
22 Sharps containers are visibly clean with
no body substances, dust, dirt or debris
23 Inappropriate re-sheathing of needles
does not occur.
* When not being used immediately the sliding lid on the sharps bin should be kept
closed but not ‘clicked’ locked.
Additional Comments:
10
Safe Storage of Vaccines
Yes No
1
The pharmacy has comprehensive
procedures/policy for the storage of
vaccines.
2
Systems are in place to ensure
distribution, compliance and monitoring of
vaccine procedures and policy. This
should include training of staff where
appropriate.
3
There is a named responsible person that
has overall responsibility for correct use,
and storage of vaccines
4
Vaccines are stored immediately upon
delivery into a dedicated refrigerator
5
The vaccine refrigerator is fit for purpose
and is not a domestic refrigerator
6
The refrigerator has an uninterrupted
electricity supply
7
The refrigerator for vaccines shows
maximum and minimum temperatures
8
Temperature checks are performed and
recorded daily
9
Recorded temperatures are within the
acceptable range of 2°c - 8°c
N/A Comments
10 There is a validated system for
maintaining the cold chain
11 The refrigerator is used for vaccine and
pharmaceuticals storage only [COSHH]
12 Vaccines are not stored in the door of the
refrigerator or in a separate drawer at the
bottom of the fridge
13 Storage of vaccines in the refrigerator is
adequate i.e. up to 50% full
11
14 Alternative and appropriate storage is
available in the event of a breakdown or
repair of the vaccine refrigerator
15 A system is in place for safe disposal of
expired/surplus/damaged vaccines
16 All vaccines are in date
17 Vaccine stocks are rotated and used
according to date
18 The top surface of the vaccine
refrigerator is not used for storage
Additional comments:
Decontamination
Standard Statement: Decontamination of re-usable medical instruments will ensure
all such instruments are adequately decontaminated prior to re-use and any
associated risks are managed.
(Obviously syringes and needles used in the administration of flu vaccines will not be reused. Furthermore, other medical devices such as CO Monitors, Peak Flow Meters, Incheck dials, etc, must be used with disposable mouthpieces. However, steps should be
taken to ensure that the equipment itself is cleaned effectively and disinfected as
appropriate.)
Yes No
1
2
3
N/A Comments
The pharmacy has comprehensive
procedures for the cleaning, disinfection,
inspection and disposal of re-usable
medical instruments
Systems are in place to ensure the
procedures for the cleaning, disinfection,
inspection and disposal of re-usable
medical instruments are available to all
staff and, furthermore, to ensure
compliance with these procedures is
monitored
There is no evidence that the
organisation is reusing single use items
Additional Comments:
12