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Entries;B  ; Sff@@093 A@@   oW TODAY'S DATE: Completed Not yet dueLateNo.Due DateCompleted DateComments PTs STATUSNote: Please ensure that the 'Entry Date' (i.e. date that PT is entered into the log) is completed, the 'Due Date' (i.e. date that thePT is due for completion) is completed, and, when appropriate, the 'Completed Date' (i.e. date that PT has been fully implemented) is completedStatusArea for Improvement Waste MgtPatient EnvironmentStorage of Chemicals - management of chemicals, including storage is under review. Education, training and monitoring of chemical storage is in place. Swipe system being trialed in Gogarty. If successful will roll out across the clinical areas#Surgical site infections preventionKThe hospital has cohorted surgical patients to specific wards and bed areasClostridium difficileIsolation Rooms-WSUHand wash sinksOAccess to clinical hand wash sinks was restricted in some multi-occupancy roomsImmediate deep clean of WSU Deep clean2Monitoring, Maintenance and Mgt of the facilities xAwareness / education on SIGHT mnemonic protocol to aide mgt of patients with suspected potentially infectious diarthoea1Preparation and Storage of anaesthetic medicationIntervention RadiologyIntraventious Medication Prep#Environmental Hygiene & MaintenanceThe overall standard of environmental and equipment hygiene in the Theatre Department was found to be sub-optimal, with unacceptable levels of dust observed in all areas inspected.Theatre 8 had unacceptable levels of dust on most surfaces. This indicated that cleaning and dust control measures were insufficient.yDeficiencies in the maintenance in the physical environment were also observed by the authority in the Theatre departmentSurfaces, finishes and flooring were damaged and poorly maintained and as such did not facilitate effective cleaning and likely facilitated the production and accumulation of dust.Infrastructure and use of PACUjPACU - has no designated isolation facilities for the mgt of patients with transmissible infections. The configuration and location of PACU is suboptimal from an infection prevention & control perspective The hospital has submitted a business case for the development of enhanced critical care capacity These works need to be progressed as a matter of priority Hand Hygiene Training & EducationJConsultant Surgeons and Anaesthetists need to attend hand hygiene trainingLocal Hand Hygiene AuditsDoor to isolation room was open and precautionary signage on door could not be clearly seen. It is recommended that doors to isolation rooms are closed where possible and that related signage is clearly visible]Anaesthetic Medication which was drawn up prior to a patients arrival in the interventional radiology suite was stored in a manner that was not in line with good practice guidance. This issue should be addressed from a hospital wide perspective.MkqAssurances could not be provided that the integrity and sterility of intravenous medications were maintained from compounding to administration. The authority recommends that the hospital reviews the practice relating to anaesthetic medication, to assure itself that the potential infection risks to patients in this regard are fully mitigated. Ref: Theatre/ Radiology_\It is recommended that integrated sharp trays containing only the blood glucose monitor and items required for a single fingerstick procedure are brought to the point of care. The authority recommends that this practice should be monitored to ensure that the risks to the patient of acquiring a healthcare associated infection are fully mitigated.-"Infection Control Team / NursingEstates & FacilitiesReview the systems and processes relating to the monitoring, management and maintenance of the physical environment and all equipment to assure compliance with Standard 3 of the Infection Prevention & Control StandardsHygiene Services / CNM3 Theatre6Hygiene Services / CNM3 Theatre / Estates & FacilitiesEstate & FacilitiesPeripheral Venous Catheter Care Bundles have not been implemented by the hospital to date. These should be progressed in line with national guidelines Dir NursingEnvironmental Hygiene Services%Clostridium difficile outbreak in WSUSuboptiminal Hygiene observed on spot check carried out by authority during visit to William Stokes unit indicated that the management of equipment and environment hygiene on the unit remains an issue. Brown staining was observed on the undersurfaces of commodes. Root cause analysis of the outbreak identified that the main contributory factor was likely to be inadequate cleaning of shared patient equipment. i6A number of syringes containing reconstituted intravenous medications were insufficiently labelled and stored directly on a worktop in anaesthetic room six. The practice of reconstituting intravenous medications prior to use was also observed in some other anaesthetic rooms during the course of the inspectionMedication Safety- theatre0Blood Glucose Monitoring- theatre and radiiology1Infection Control Team /Clinical Director Surgery%0#COO/CD for Perioperative Serivices Page.Nurse Practice Development / Medication SafetyRadiology / Anaesthesia(Anaesthesia / Nurse Practice developmentAn open multi dose vial of heparin sodium was observed in a clean utility room adjacent to the cardiac catherisation laboratory, the vial was not labelled to indicate the date of opening. It is recommended that multi-dose vials are designated for single patient use where possible. Such vials should be labelled with the date of opening and discarded within recommended timeframe specified by the manufacturer. Nurse Practice Development~The theatre was served by only one patient toilet: this does not sufficiently meet the throughput of patients. The toilet was only accessible via the "dirty" utility room,giving unauthorised access to hazardous cleaning agents and material. No dedicated hand hygiene facilities in a dirty utility room serving theatre 8. Sanitary facilities need to be reviewed in Theatre department-Infection Control Team / Estate & Facilities3Nurse Practice development / Infection Control Team2Infection Control Team / Nursing, Hygiene Services8Technical Services / Hygiene Services/IPC Team/ Nursing'Infection Control Team / Microbiologist(Anaesthesia / Nurse Practice Development$Large amounts of equipment, supplies and extraneous items stored along corridor along side waste bins in Theatre department disosal corridor. Storage areas need to be appropriate and adequate for the operational requirements of each clinical area - appropriate segregation of functional areas The design of all clinical hand sinks in the Theatre Department did not conform to health Building Note 00-10 Part C: sanitary assembluies. The design of some clinical hand wash sinks in Radilogy (excluding intervention radiology) were not compliant with HBN 00-10. 7Infection Control team / Directof Lab/ Director of QSRMsRecommended that targeted education and audit is performed in order to drive improvement in hand hygiene complianceResponsible Area/PersonIssues and recommendationsQIP 2015 - Health Care Associated Infections- a summary of remaining quality improvement activities from 2014/5 HIQA inspections Completed Design phase is now completed. The issue will be addressed directly when funding from the HSE is provided to implement the proposed design. In the meantime, an interim redesign proposal has been put forward with a view to completing by the end of 2017. Design phase is now completed. The issue will be addressed directly when funding from the HSE is provided to implement the proposed design.The rooms/bays are currently being upgraded across the hospital. In parellel, HBN 00-10 compliant sinks are being introduced. Tallaght Hospital Sharps - in clinical areas. Certain bins were not closed on inspection. 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