Workplace Naloxone Training Checklist (Nasal Spray)
Naloxone may be administered only by personnel who’ve received proper training. Here’s a Checklist you can use to verify such training where naloxone is administered via nasal spray.
| Knowledge Check for Administering Naloxone | Trainer Initials | Trainee Initials | Date |
|---|---|---|---|
| Successful completion of naloxone administration training | |||
| Accurately identifies location(s) of naloxone at the workplace | |||
| Accurately identifies necessary supplies | |||
| Accurately reads and follows instructions on naloxone box | |||
| Accurately identifies Workplace Naloxone Coordinator | |||
| Accurately describes incident reporting procedures | |||
| Accurately describes incident documentation procedures | |||
| Skills Check for Administering Naloxone | Trainer Initials | Trainee Initials | Date |
| Assessing the victim including shake, shout and sternal rub | |||
| Calling/instructing someone to call 911 and activate workplace emergency response | |||
| Obtaining and correctly administering Naloxone following each step below: | |||
| 1. Lay victim on their back to administer Naloxone | |||
| 2. Remove medication from box, peel back tab with a circle to open | |||
| 3. Hold Naloxone spray with thumb on the bottom of the plunger and the third and middle fingers on either side of the nozzle | |||
| 4. Tilt the victim’s head back while using your hand to provide support under the neck | |||
| 5. Gently insert the tip of the nozzle until the fingers on either side of the nostril are against the bottom of the victim’s nose | |||
| 6. Press the plunger firmly to give the dose of Naloxone nasal spray | |||
| 7. Remove Naloxone nasal spray and turn victim to their side (recovery position) | |||
| 8. Monitor victim, administer rescue breathing if needed, (i.e., if no response to talking, touch or pain, additional Naloxone nasal spray may be administered every 2-3 minutes if available, until the victim responds or EMS arrives) | |||
| 9. If needed, follow steps 2-8 using a new Naloxone nasal spray in the other nostril | |||
| 10. Put the used Naloxone nasal spray back in the box and give to EMS for disposal | |||
| 11. Document administration according to Company policy/protocol | |||
| Training is valid for one year; review during the year is highly recommended |