Use this SOP to maintain infection-control devices, supplies, hand hygiene, protective practices, cleaning, sterilization, housekeeping, and waste handling in every patient-care area. Handwashing is one of the most effective ways to prevent infection transmission among patients and personnel and is the single most important means of preventing the spread of infection.

📚 Resources Needed

  • A sink in every patient-care area and a handwashing facility in the exam room and/or utility room, preferably with 4–6-inch wing-tip faucet handles or hands-free controls

  • An adequate supply of running potable water

  • Soap, including antibacterial soap where required

  • Single-use paper towels or a hot-air drying machine and an appropriate garbage receptacle

  • An antiseptic hand cleanser, alcohol-based hand rub, or antiseptic towelettes for temporary use when running water is not readily available

  • Disposable gloves and gloves designed to withstand instrument-cleaning procedures

  • Protective eyewear or masks with eye shields, protective masks, and disposable fluid-resistant gowns

  • Sharps containers

  • Cleaning solutions appropriate to the level of contamination and compliant with applicable guidelines

  • A 10% bleach solution mixed daily or a germicidal solution effective against tuberculosis, hepatitis, and HIV

  • A heat or heat-pressure sterilizer, including an autoclave, for non-disposable critical instruments

  • Hepatitis B vaccination-status or vaccine-declination records for personnel with occupational exposure to bloodborne pathogens

  • The Handling and Control of Infections/Biohazardous Wastes procedures

✅ Before You Start

  • Confirm the required infection-control devices and supplies are available in every patient-care area.

  • Confirm the handwashing facility has running potable water, soap, and single-use towels or a hot-air drying machine.

  • Assess the planned procedure for possible exposure of the eyes, face, mouth, nose, clothing, arms, or other exposed body parts to potentially contaminated substances.

  • Select the required eye protection, mask, gloves, and fluid-resistant gown before the procedure begins.

  • Confirm any 10% bleach solution intended for use was mixed that day.

  • Identify whether any reusable instrument is a critical instrument that has penetrated soft tissue or bone or contacted mucous membranes.

  • Use an approved temporary antiseptic cleanser, alcohol-based hand rub, or antiseptic towelette only when running water is not readily available.

🚀 Tips & Tricks

  • Keep handwashing supplies, disposable gloves, protective equipment, sharps containers, and waste receptacles stocked near the point of care.

  • When in doubt about whether handwashing is necessary, wash your hands.

  • Treat both entering and leaving the room as required handwashing points.

  • Keep approved temporary hand-cleansing products accessible for occasions when running water is not readily available.

  • Mark the preparation date on daily-mixed bleach solution so staff can verify it is current.

  • Separate potentially contaminated instruments and waste from clean items to help prevent cross-contamination.

📘 Instructions

Step 1: Maintain Infection-Control Devices And Handwashing Supplies

  • Provide adequate infection-control devices and supplies in all patient-care areas.

  • Each patient-care area must include a sink, preferably with 4–6-inch wing-tip faucet handles or hands-free controls; running potable water; soap; paper towels or a hot-air drying machine; an appropriate garbage receptacle; disposable gloves; and a sharps container.

Step 2: Maintain Hepatitis B Vaccination Records

  • Offer the Hepatitis B vaccine and any necessary booster, in accordance with Cal/OSHA requirements, to all personnel who have occupational exposure to bloodborne pathogens.

  • Keep documentation of each affected team member's vaccination status or vaccine declination on file.

Step 3: Use Required Personal Protective Equipment

  • Wear protective eyewear or a mask with an eye shield during procedures in which exposure to potentially contaminated substances is likely.

  • Wear a protective mask during procedures when the face, mouth, or nose may be splashed with potentially contaminated substances.

  • Wear a disposable, protective, fluid-resistant gown during procedures when clothing may be contaminated with blood or body fluids.

  • Ensure the gown covers the arms and all exposed body parts.

Step 4: Perform Hand Hygiene At Every Required Point

  • Perform thorough handwashing upon entering the room and again when leaving the room.

  • Wash hands before and after contact with a patient.

  • Wash hands before performing invasive procedures.

  • Wash hands before caring for newborn infants.

  • Wash hands before and after touching wounds.

  • Wash hands after touching inanimate sources that are likely to be contaminated, including specimen containers or bed linens.

  • Wash hands whenever gloves are removed.

  • Wash hands after direct patient contact or indirect contact with blood or any body substance.

  • Use antibacterial soap in special areas, before performing invasive techniques, and after any exposure to blood or body fluid.

  • Wash hands whenever personnel are in doubt about whether handwashing is necessary.

Step 5: Perform Routine Handwashing Correctly

  • Wet hands using running potable water and apply soap.

  • Vigorously rub the soap-lathered hands together for at least ten seconds.

  • Thoroughly rinse the hands under a stream of water.

  • Dry the hands using a single-use towel or a hot-air drying machine.

Step 6: Use An Approved Temporary Alternative When Water Is Unavailable

  • When running water is not readily available, use an antiseptic hand cleanser, alcohol-based hand rub, or antiseptic towelettes.

  • Use these alternatives only until running water becomes available.

Step 7: Handle And Clean Contaminated Items

  • Handle potentially contaminated instruments carefully while wearing gloves designed to withstand the cleaning procedures.

  • Clean instruments, equipment, and environmental surfaces with solutions appropriate to the level of contamination and that meet applicable guidelines.

Step 8: Sterilize Critical Instruments

  • Treat an instrument as critical when it has penetrated soft tissue or bone or has come in contact with mucous membranes.

  • If a critical instrument is not disposable, sterilize it in a heat or heat-pressure sterilizer, including an autoclave.

Step 9: Disinfect Touch And Splash Surfaces Immediately

  • Treat a surface as a touch and splash surface when it is exposed to splatter of blood or body fluids contaminated by treatment personnel.

  • Immediately disinfect the surface with either a 10% bleach solution mixed daily or a germicidal solution effective against tuberculosis, hepatitis, and HIV.

Step 10: Prevent Cross-Contamination

  • Use appropriate housekeeping techniques to prevent cross-contamination.

Step 11: Dispose Of Potentially Contaminated Waste

  • Dispose of potentially contaminated waste according to the Handling and Control of Infections/Biohazardous Wastes procedures.

🛠 Troubleshooting

Required Supplies Are Missing From A Patient-Care Area

Do not begin the procedure until the required sink access, soap, drying method, garbage receptacle, disposable gloves, sharps container, and procedure-specific protective equipment are available.

Running Water Is Not Readily Available

Use an antiseptic hand cleanser, alcohol-based hand rub, or antiseptic towelettes until running water is available.

Soap Or A Drying Method Is Missing

Do not rely on an incomplete routine-handwashing station. Restore soap and either single-use towels or a hot-air drying machine.

You Are Unsure Whether Handwashing Is Necessary

Wash your hands. The protocol requires handwashing whenever personnel are in doubt.

Potentially Contaminated Material Splashes A Surface

Disinfect the affected touch or splash surface immediately with daily-mixed 10% bleach solution or a germicidal solution effective against tuberculosis, hepatitis, and HIV.

A Reusable Critical Instrument Cannot Be Sterilized

Do not reuse the instrument. A non-disposable critical instrument must be sterilized in a heat or heat-pressure sterilizer, including an autoclave, before reuse.

Vaccination Documentation Is Missing

Confirm the Hepatitis B vaccine and any necessary booster were offered in accordance with Cal/OSHA requirements, then obtain and retain the vaccination-status or declination documentation.

✅ Completion Check

  • Every patient-care area has the required sink, running potable water, soap, drying method, garbage receptacle, disposable gloves, and sharps container.

  • Personnel with occupational exposure to bloodborne pathogens were offered the Hepatitis B vaccine and necessary booster, and vaccination or declination documentation is on file.

  • Personnel used protective eyewear or a mask with an eye shield, a protective mask, and a disposable fluid-resistant gown whenever the applicable exposure risk existed.

  • Protective gowns covered the arms and exposed body parts.

  • Thorough handwashing was performed upon entering and leaving the room and at every required point of care.

  • Hands were washed before and after patient contact, before invasive procedures, before caring for newborn infants, before and after touching wounds, after touching likely contaminated items, after glove removal, and after direct or indirect contact with blood or any body substance.

  • Routine handwashing included vigorously rubbing soap-lathered hands together for at least ten seconds, rinsing under running water, and using a single-use towel or hot-air drying machine.

  • Approved temporary antiseptic hand-cleansing products were used only until running water became available.

  • Antibacterial soap was used in special areas, before invasive techniques, and after exposure to blood or body fluid.

  • Personnel washed their hands whenever they were in doubt about the need to do so.

  • Potentially contaminated instruments were handled with cleaning-resistant gloves, and instruments, equipment, and environmental surfaces were cleaned with appropriate compliant solutions.

  • Non-disposable critical instruments were sterilized in a heat or heat-pressure sterilizer, including an autoclave.

  • Touch and splash surfaces were disinfected immediately with daily-mixed 10% bleach solution or an effective germicidal solution.

  • Appropriate housekeeping techniques were used to prevent cross-contamination.

  • Potentially contaminated waste was disposed of according to the Handling and Control of Infections/Biohazardous Wastes procedures.