Title Page

  • Procedure Date

  • Observed by

  • Location

  • Department

  • Department

  • Department

  • Department

  • Specify Department

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  • Surgery Type

  • Emergent

  • Patient Name

  • Patient MRN

  • Attending Surgeon

  • Resident Surgeon

  • Intern Surgeon

  • Anesthesiologist/CRNA

  • Circulating RN

  • OR Technician

  • Vendor

  • Other

Procedural Observations

1. Skin Antisepsis (Preoperative bathing)

  • CHG shower or bath three days before surgery.

  • Chlorhexidine Gluconate (CHG) soap shower or bath the night before surgery.

  • CHG soap shower or bath the day of surgery.

  • If patient did not bathe with CHG before surgery, the skin is washed at the surgical site before performing pre-op skin antisepsis.

  • Comments:

2. Skin Antisepsis (Intraoperative skin preparation).

  • If hair removal necessary, hair is removed in the pre-op area.

  • If additional hair removal necessary, hair is removed with a clipper.

  • Skin at incision site is free of soil, debris, and emollients.

  • Alcohol-containing antiseptic agent is used.

  • Non-scrubbed team member applying skin antiseptic performs hand hygiene before applying the skin antiseptic.

  • Sterile gloves are worn when applying the skin antiseptic.

  • Surgical attire that covers the team member's arms are worn when applying the skin antiseptic.

  • Sterile supplies are used to apply the skin antiseptic.

  • Skin antiseptic was applied using aseptic technique and following manufacturer's instructions for use.

  • If incision site is generally clean, skin antiseptic applied at the incision site and moves toward the periphery.

  • If incision site is more highly contaminated than the surrounding skin (e.g., open wound), area with a lower bacterial count is prepped first.

  • Applicator is discarded after contact with the periphery and another sterile applicator used for additional applications.

  • When performing pre-op skin antisepsis of the hand/foot, antiseptic is applied to all surfaces b/w fingers/toes and does not drip clean to dirty.

  • The skin antiseptic is removed from the patient's skin at the end of the surgical procedure.

  • Comments:

3. Surgical Attire

  • Peri-op personnel entering operating room are wearing clean scrub attire including freshly laundered or single-use long-sleeved jacket snapped closed with cuffs down to the wrists.

  • Top of scrub suit is secured at the waist or tucked into pants.

  • All personal clothing is contained within scrub attire.

  • Personnel are wearing disposable surgical head cover or hoods that cover all hair and scalp skin, including facial hair and sideburns.

  • Shoe covers are worn in instances when gross contamination can reasonably be anticipated (e.g. orthopedic procedures).

  • Surgical mask covers the mouth and nose, and all straps are tied and secured in a manner to prevent venting.

  • Masks are not allowed to hang around the neck.

  • Masks are removed by handling only the mask ties.

  • Eye protection is worn.

  • Jewelry (e.g. earrings, necklaces, bracelets, watches, rings) are contained within the scrub attire.

  • Briefcases, backpacks, cell phones, pagers, and other personal items are cleaned with a low-level disinfectant and not placed on the floor.

  • Comments:

4. Opening/Introduction of Sterile Supplies onto the Sterile Field

  • Sterile field is prepared as close as possible to the time of use.

  • Personnel perform surgical hand scrub and don sterile gown and gloves before setting up sterile supplies.

  • Only sterile items come in contact with the sterile field.

  • Separate setups are used for procedures that involve both abdominal and perineal areas.

  • Sterile items are inspected for proper processing, packaging, andpackage integrity immediately before presenting to the sterile field.

  • Chemical indicator is inspected for color change.

  • Heavy or sharp items are presented directly to the scrubbed team member or opened on a separate clean, dry surface.

  • When opening items in peel pouches, the contents are not allowed to slide over the unsterile edges of the package.

  • Rigid sterilization containers are inspected (e.g. external locks, latch filters, valves, tamper-evident devices, and external chemical indicators) and opened on a clean, flat, and dry surface.

  • Rigid sterilization container lid is lifted up and toward the person opening the container and away from the container.

  • Rigid sterilization container lid is inspected for integrity of the filter/valve/gasket.

  • If organic material or other debris is found on an instrument or item in a sterile set, the entire set is considered contaminated and corrective actions are immediately taken.

  • Sterile transfer devices (e.g. sterile vial spike, filter straw, plastic catheter) are used when transferring medications/solutions to sterile field.

  • Stoppers are not removed from vials for the purpose of pouring medications (unless specifically designed for removal and pouring by the manufacturer).

  • Sterile field is constantly monitored and not left unattended.

  • Breaks in technique are immediately recognized and corrected.

  • Comments:

5. Donning/Wearing Sterile Gowns & Gloves

  • Hand hygiene is performed before entering the OR where sterile supplies are open.

  • Sterile technique is used when donning/wearing sterile gown & gloves.

  • Surgical hand scrub is performed before donning sterile attire.

  • Sterile gown & gloves are donned in a sterile area away from main instrument table.

  • Sterile gown is considered sterile only from chest to level of the sterile field and from 2 inches above elbow to the cuff (all other areas are considered unsterile including the cuff once the team members' hands pass through and beyond the cuff).

  • Two pairs of surgical gloves are worn (preferred).

  • Gloves are changed at appropriate times/intervals (e.g. suspected contamination, after direct contact with methylmethacrylate, visible defect, every 90-150 minutes).

  • Comments:

6. Draping

  • Sterile equipment is covered on the top, bottom, and sides with sterile barrier materials before being introduced to or brought over a sterile field.

  • Gloved hands are shielded during draping.

  • Drapes are placed in a manner that does not require scrubbed team members to lean across an unsterile area and prevents the front of the surgical gown from contacting an unsterile surface.

  • Drapes are placed from the surgical site to the peripheral areas.

  • Drapes are not moved after being placed.

  • Only the top surface of a sterile, draped area is considered sterile (items that fall below the sterile area are considered contaminated).

  • Only iodophor-impregnated plastic adhesive incise drapes are used (for prevention of SSI).

  • Comments:

7.Traffic Control/Moving within the Sterile Environment

  • Scrubbed members remain close to the sterile field and touch only sterile areas or items.

  • Scrubbed members do not leave the sterile field to retrieve items from the sterilizer.

  • Scrubbed members keep their hands and arms above the waist level at all times.

  • Scrubbed members do not fold their arms/place hands in axillary area.

  • Scrubbed members avoid changing levels and are seated only when the entire procedure is performed at that level.

  • Scrubbed members pass "back-to-back" or "face-to-face".

  • Unsterile personnel face the sterile field on approach, do not walk between the sterile fields or persons, and maintain a 12 inch distance from the sterile field and scrubbed persons at all times.

  • Conversations in the presence of a sterile field are kept at a minimum.

  • Number and movement of individuals involved in the procedure is kept at a minimum.

  • Comments:

8. Major OR/Procedure Room Findings

  • There were no other major findings in the OR/Procedure room.

  • What were the additional findngs:

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