D.3_Appendix B_Competency Assessment_Hand Hygiene and Garbing.pdf
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- Sterile Compounding Services
- Solicitation number
- 36C25727Q0032
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This document is Appendix B of a competency assessment tool for evaluating pharmacy staff proficiency in hand hygiene and garbing procedures required for sterile compounding environments.
The assessment is designed to evaluate both initial and ongoing competency through observation by qualified pharmacy staff. The evaluator documents competency by initialing each criterion in designated spaces. The assessment covers three primary competency areas: donning procedures, hand hygiene and gloving, and doffing procedures. Donning requirements include presenting in clean attire, removing extraneous items and jewelry, adhering to nail length restrictions (maximum ¼ inch), securing long hair, cleaning eyeglasses with sterile 70% isopropyl alcohol, donning facemask with specific positioning requirements (folds down, shiny side out, metal bar bent to nose bridge), optional beard cover or hood, and shoe covers placed on the clean side of the demarcation line. Hand hygiene and gloving procedures require using an individually packaged disposable nail pick, washing hands and forearms with soap and warm water for at least 30 seconds, drying with low-linting towels, selecting an appropriately sized gown without defects, sanitizing hands with waterless alcohol-based surgical hand rub before donning sterile gloves, and ensuring proper glove fit. For hazardous drug (HD) buffer rooms or containment segregated compounding areas (C-SCA), employees must don additional protective equipment including an HD gown, second pair of shoe covers, and second pair of chemotherapy gloves. Doffing procedures require removing gloves and gown in the anteroom or outside the perimeter, discarding or appropriately storing the gown, removing mask and head cover on the dirty side of demarcation, and washing hands before leaving the compounding suite. The form includes spaces for employee and evaluator information, evaluation date, competency type designation, and additional comments.
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?.## APPENDIX B_COMPETENCY ASSESSMENT_HAND HYGIENE AND GARBING
Appendix B
Hand Hygiene and Garbing Competency Assessment
Employee: ________________________________ Position:
Evaluator: ________________________________ Initials: _____
Date of Evaluation: ___________
Type: ___ Initial Competency ___ Ongoing Competency
Observations and subsequent evaluation must be made by qualified pharmacy staff. Using the space designated next to each criterion, the evaluator will initial to signify that the criterion has been satisfied.
Competency Assessment: Hand Hygiene and Garbing
DONNING
Skill Initials Comments
Presents in a clean, appropriate attire and manner.
Removes extraneous personal clothing (scarves, vests, sweaters, hats, etc.) and wears cleanroom appropriate clothing (scrubs are preferred).
Wears no cosmetics or jewelry (watches, rings, earring, earbuds, including piercings) upon entry into anteroom or segregated compounding area (SCA). Phones and badge lanyards must also be removed.
Neither brings nor stores food or drink or chews gum in the anteroom or SCA.
Nails do not extend more than ¼ inch beyond the fingertip and does not wear artificial nails, nail extenders, or nail polish.
Long hair is tied back and up with a band.
If wears prescription eyeglasses, cleans and disinfects the frames and lenses with sterile 70% isopropyl alcohol (sIPA) immediately before entering anteroom or SCA provided. (Other cleaners and disinfectants may be used if specifically recommended by the manufacturer to prevent damage to eyewear). Also ensures glasses are secured so they will not require adjustment.
Demonstrates awareness of and observes the line of demarcation separating clean and dirty sides of the anteroom when performing required activities.
Dons facemask and head cover ensuring that all hair is covered by looking in a mirror to verify, that mask is donned with folds facing down on the outside, the mask’s shiny side is outside (if cleanroom grade mask), metal bar is bent to conform to bridge of nose and bottom of mask is pulled down underneath chin.
Optional: Dons beard cover, if necessary, for small goatee or hood if full beard, hijab, or hair that does not fit in the bouffant cap.
Dons shoe covers one at a time, placing the covered or designated shoe on the clean side of the line of demarcation as appropriate. (Note: if SCA, then shoe covers are the last item to don carefully without touching shoes before crossing perimeter line).
HAND HYGIENE AND GLOVING
Takes individually packaged disposable nail pick out of the bin.
Wets hands and forearms, and lathers using soap and warm water, then uses disposable nail pick to clean underneath fingernails.
Lathers hands and forearms for at least 30 seconds.
Rinses hands and forearms with warm water.
Dries hands and forearms using a low-linting towel.
Selects the appropriately sized gown examining for any holes, tears, or other defects.
Dons gown and closes all the way to the neckline.
Enters the buffer room or if SCA, crosses over the perimeter line.
Sanitizes all surfaces of hands using a waterless alcohol-based surgical hand rub with persistent activity and allows hands to dry thoroughly before donning sterile gloves.
Selects and dons appropriately sized sterile gloves ensuring that there is a tight fit with no excess glove material at fingertips.
Optional: Puts on goggles that are dedicated to cleaning if performing cleaning activities above the head or with agents which can irritate the eyes.
When entering HD buffer room/C-SCA, dons additional HD gown, second pair of shoe covers, and second pair of chemotherapy gloves.
DOFFING
When leaving anteroom or SCA: Doffs gloves in anteroom or outside perimeter if SCA. Doffs gown and discards it (if finished compounding for the day) or marks with initials on inside collar and hangs it on a hook on the clean side of the anteroom or outside the perimeter of the SCA (if not visibly soiled and is intact) where it may be reused during the same work day only.
Crosses the line of demarcation to the dirty side of the anteroom (or outside the perimeter if an SCA) and removes and discards mask, head cover beard cover (if used) and shoe covers.
When exiting HD buffer room/C-SCA, doffs HD gown and exterior pair of shoe covers before crossing over line of decontamination in the HD bufffer room. Washes hands in the anteroom sink before leaving sterile compounding suite.
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File details come from the government source that posted it. Updated .