265
Appendix 6: Hand Hygiene 
Data Collection Sheet
266 ◾  Appendix 6: Hand Hygiene Data Collection Sheet
Collected by:
Observable by
asking person
Hand Hygiene Observation and Contributing Factor Form
Date of observations:
Possible Contributing Factors to Washing
Observable
Observation Number
Unit name (2 South, ITU, etc)
Circle time of observation (AM is 0801-1700, PM is 1701-0800)
Did person perform hand hygiene?
Dispenser location not in path of person or obstructed/hidden
Dispenser empty
Dispenser broken
Leaves patient room to use shared equipment
Hands full: Supplies/Equipment (e.g. food trays, lab supplies)
Hands full: Meds
Gloves - Did not wash before or after gloving
Urgency to act for patient safety concern
Person entering/exiting followed someone who did not wash
Frequent entry and exit
Admissions or discharge process
Isolation area (gown + gloves when required)
Lack of immediate feedback to person for hand hygiene compliance
Distractions/Forgets/Lack of knowledge/Chose not to wash
Perception that if nothing is touched in the patient care area hand hygiene is not necessary
Perception of skin irritation or dislike of alcohol based cleanser
Comments
1 2 4
5
6 7
8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
1 AM PM
RN T MD Diet Rx PHL HSK
CATR Stf Por ODP Con
1 2 3 4 5 Yes No
2 AM PM
RN T MD Diet Rx PHL HSK
CATR Stf Por ODP Con
1 2 3 4 5 Yes No
3 AM PM
RN T MD Diet Rx PHL HSK
CATR Stf Por ODP Con
1 2 3 4 5
Yes No
4 AM PM
RN T MD Diet Rx PHL HSK
CATR Stf Por ODP Con
1 2 3 4 5 Yes No
5 AM PM
RN T MD Diet Rx PHL HSK
CATR Stf Por ODP Con
1 2 3 4 5
Yes No
6 AM PM
RN T MD Diet Rx PHL HSK
CATR Stf Por ODP Con
1 2 3 4 5 Yes No
7 AM PM
RN T MD Diet Rx PHL HSK
CATR Stf Por ODP Con
1 2 3 4 5 Yes No
8 AM PM
RN T MD Diet Rx PHL HSK
CATR Stf Por ODP Con
1 2 3 4 5 Yes No
9 AM PM
RN T MD Diet Rx PHL HSK
CATR Stf Por ODP Con
1 2 3 4 5
Yes No
10 AM PM
RN T MD Diet Rx PHL HSK
CATR Stf Por ODP Con
1 2 3 4 5 Yes No
Instructions:
1. Use a separate row for each entry or exit.
2. When known, check any contributing factor for each observation.
3. Emergency situations are EXCLUDED from the data collection process.
Count of "Yes"
Count of observations (rows used)
24
Calculate compliance
for this sheet
=
=
Circle role of health care professional observed
(RN=Nurse, T=erapy, HSK= Housekeeping, CATR=Catering,
Stf = eatre Staff, Por=eatre Porter, Phl=Phlebotomist
Con=Consultant) all others please identify in the comments section)
1 Before Patient contact 2 Before aseptic task 3 After fluid risk
4 After Patient contact 5 After contact with Pt surroundings
Figure A6.1

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