Eating, drinking, smoking, applying cosmetics or lip balm and handling contact
lenses is prohibited in work areas where there is potential for exposure to blood
borne pathogens.

Perform control tests and document on QA logs

In the locked storage room

Yes

Court Order
Report to Local Health Department for follow up of tx
Express harm self or others

Document the out of range temperature. Recheck temperature. Contact Meggan Leary

Center Number, Autoclave number (if more than one), date, initials

When they reach the fill line (approx. 2/3 full)

No.

Iron Mountain Storage
Yes, work with CM to retrieve them

Log out- restrict access to patients and peers to use your log in

1. Immediately check the autoclave for proper use and function and repeat the spore
test. A single positive spore test result probably does not indicate sterilizer malfunction. Objects do not need to be re-sterilized because of a single positive spore test
unless the sterilizer or the sterilization process is found defective. Sterilizer should be
removed from service and sterilization operating procedures reviewed to determine
whether operator error could be responsible.
2. All sterilization indicator strips must continue to turn the appropriate color.
3. If a spore test remains positive:
• discontinue use of the autoclave
• immediately notify supervisor
• remove all sterilized packs from inventory dated after the last negative
spore test result
• use alternative equipment (e.g. disposable speculum)
• call for service
When repair is completed, rerun biological spore test prior to sterilizing equipment for use.

Discarded blood, products of blood and anything caked, soaked or dripping with
blood.

Yes

Minimum of annually to women having sex with men or with any change in sex partner

Vials must be discarded if there is evidence of contamination.If a multi-dose vial has been opened or accessed (e.g., needle-punctured) the vial must be dated and discarded in accordance with manufacturer’s instructions and state/local regulations. If no specific guidelines are provided, CDC recommends discarding the vial within 28 da

CDC website
Sharepoint

Need to track what was used and reorder supplies to stay stocked.

Sale is completed as an donation in the EHR/PM system. No patient information is collected.

I.Package — the package of medication in question must be held in a secure place at the affiliate, as later transfer to the manufacturer or the FDA may be necessary. There must be no attempt to manipulate or otherwise alter the package, as it may constitute evidence in a criminal suit or other action.
II.Remaining Stock — Remaining stock of medication with the same lot number must be identified, put aside, and not dispensed to patients until the problem has been resolved.
III.Notifications — ARMS must be notified immediately by telephone for evaluation of the situation and provision of further instructions. The affiliate must not take any additional steps (such as notification of the pharmaceutical company, FDA, other patients who may have been exposed to the product, and the media) until it receives guidance from ARMS.

Manifest with specimen labels, kept with tracking number of shipment. Kept for 30 days.

Inforth in EHR system

CFU follows up with test results and with the lab

Create an encounter in EHR labeled as COMMUNICATION. Document how the contact was made, what was requested, what the resolution was, and who they spoke with.

The label must also include the following information, which may be added by hand at the time of dispensing:
A.Date of the prescription
B.Name of the patient
C.Directions for use including frequency and route of administration
D.Name of the prescriber
E.Number of refills, if applicable