Information
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Document No.
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Audit Title
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
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Select date
Surgical Attire
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Staff changed into scrubs at the hospital
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Top is secured at waist, tucked in or close to body
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Al hair is covered
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No visible jewelry worn by scrubbed and non-scrubbed staff
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Mask is worn by (secured with both ties) in the presence of open sterile items and equipment
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Cover gowns/jackets are worn and secured to prevent inadvertent contamination while walking past sterile field
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Dedicated shoes or shoe covers are worn
Sterile Technique
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Sterile field is prepared close to time of surgery <1 hour
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Sterile items are transported in covered or enclosed cases/carts
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Sterile packages are inspected for punctures, tears, and expiration dates
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Sterile field is maintained troughout the procedure with traffic patterns established with a minimum of one foot perimeter respected by the unsterile personnel
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Sterile items are presented to scrubbed person or placed securely on field
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Liquids are poured only once, without splashing, and the remainder is discarded
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Draping is accomplished in a sterile manner:<br> * Draping is performed by a minimum of two people<br> * Hands are "cuffed" while presenting drapes to unsterile personnel<br> * Anesthesia screen is not dropped prior to placement<br> * Drapes are not lifted or moved after placement
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Items are flashed sterilized only in an emergency situation and a closed container is used or transport to the sterile field
Surgical Hand Scrub
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Scrub is performed according to manufacturer's directions and aseptic technique
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Scrubbed personnel do not contaminate themselves while gowning and gloving
Time Out
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Observe Universal Protocol "Time Out"
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Site marked prior to entry into OR suite (in pre-op holding area)
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Circulator calls "TIME OUT"
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Circulator checks patient's ID bracelet- patient identificiation
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Circulator states the correct site
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Circulator reads aloud the surgical procedure to be done
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Outpatient chart review- H&P reviewed and documented
Skin Prep
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Hair is removed using clippers
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Skin prep is performed according to manufacturer's directions and aspectic technique
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Type of Prep used
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Sufficient drying time is allowed prior to draping
Traffic
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Traffic in and out of the room is kept to essential personnel/tasks
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The traffic pattern during the case avoids the sterile field whenever possible
Environmental Cleaning
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Horizontal surfaces are free of dust and organic debris
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After procedure, reusable patient items such as straps are cleaned between uses
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After procedure, visibly soiled areas of the floor (three to four feet perimeter around the bed) is mopped free of all blood and debris
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OR doors are closed between cases
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Scrub tech removes excess tissue from instruments
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Enzymatic spray prior to delivery to CS
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Operating room's environmental temperature and humidity temperature range 68-73 degrees and humidity range 30-60%. Staff takes and documents corrective action if temperature and humidity ranges are not met
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Linen, equipment and supplies are properly stored within the operating room and OR department, including appropriate covers and storage practices to minimize the potential for dust and contamination
Medications
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Medications are labeled appropriately when in use
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Refrigerators are specific for medications, staff foods, etc.
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Safety devices are used whenever possible
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Sharps are removed and disposed of appropriately at the completion of each case
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Sharps containers are accessible, secured to wall/counter and emptied when the "full" line is reached
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Unused medications/fluids are disposed of at the end of each case
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Fluid warmers are checked for approved temperature ranges each day the OR is functioning. If the OR is closed it is documented on the warmer log.
Cleaned / Soiled Areas
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Dirty / clean equipment is stored separately
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Glass is disposed of in rigid sharps containers
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Biohazard waste is labeled and covered
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Cleaning supplies are labeled
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Approved cleaning supplies
General Infection Prevention
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Soiled linens are placed in designated covered hampers
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Under sink storage is limited to disinfectants / cleaners
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No eating or drinking in patient care area
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Clean equipment is labeled clean / clean label removed for used equipment
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All sterile supplies are dry with intact packaging, not stored on the floor
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Low storage areas must have solid surface shelving
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Storage of sterile supplies is 8-10" above the floor and 2" away from exterior walls
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Ice scoop is not stored in the ice machine
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Staff know where to find and how to access infection prevention policies and procedures
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CDC isolation guidelines are available on isolation carts or other designated areas in the department
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Staff are aware of when to use Airborne isolation and which rooms are negative pressure
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Staff are knowledgable about blood spill protocol
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Staff know the kill time for disinfectants used
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Staff have access to and are familiar with the MDRO list
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Staff have knowledge of hand hygiene requirements and practice these requirements
