Title Page
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Procedure Date
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Observed by
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Location
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Department
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Department
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Department
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Department
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Specify Department
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Specify clinic:
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Surgery Type
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Emergent
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Patient Name
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Patient MRN
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Attending Surgeon
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Resident Surgeon
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Intern Surgeon
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Anesthesiologist/CRNA
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Circulating RN
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OR Technician
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Vendor
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Other
Procedural Observations
1. Skin Antisepsis (Preoperative bathing)
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CHG shower or bath three days before surgery.
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Chlorhexidine Gluconate (CHG) soap shower or bath the night before surgery.
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CHG soap shower or bath the day of surgery.
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If patient did not bathe with CHG before surgery, the skin is washed at the surgical site before performing pre-op skin antisepsis.
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Comments:
2. Skin Antisepsis (Intraoperative skin preparation).
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If hair removal necessary, hair is removed in the pre-op area.
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If additional hair removal necessary, hair is removed with a clipper.
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Skin at incision site is free of soil, debris, and emollients.
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Alcohol-containing antiseptic agent is used.
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Non-scrubbed team member applying skin antiseptic performs hand hygiene before applying the skin antiseptic.
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Sterile gloves are worn when applying the skin antiseptic.
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Surgical attire that covers the team member's arms are worn when applying the skin antiseptic.
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Sterile supplies are used to apply the skin antiseptic.
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Skin antiseptic was applied using aseptic technique and following manufacturer's instructions for use.
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If incision site is generally clean, skin antiseptic applied at the incision site and moves toward the periphery.
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If incision site is more highly contaminated than the surrounding skin (e.g., open wound), area with a lower bacterial count is prepped first.
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Applicator is discarded after contact with the periphery and another sterile applicator used for additional applications.
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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.
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The skin antiseptic is removed from the patient's skin at the end of the surgical procedure.
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Comments:
3. Surgical Attire
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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.
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Top of scrub suit is secured at the waist or tucked into pants.
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All personal clothing is contained within scrub attire.
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Personnel are wearing disposable surgical head cover or hoods that cover all hair and scalp skin, including facial hair and sideburns.
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Shoe covers are worn in instances when gross contamination can reasonably be anticipated (e.g. orthopedic procedures).
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Surgical mask covers the mouth and nose, and all straps are tied and secured in a manner to prevent venting.
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Masks are not allowed to hang around the neck.
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Masks are removed by handling only the mask ties.
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Eye protection is worn.
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Jewelry (e.g. earrings, necklaces, bracelets, watches, rings) are contained within the scrub attire.
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Briefcases, backpacks, cell phones, pagers, and other personal items are cleaned with a low-level disinfectant and not placed on the floor.
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Comments:
4. Opening/Introduction of Sterile Supplies onto the Sterile Field
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Sterile field is prepared as close as possible to the time of use.
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Personnel perform surgical hand scrub and don sterile gown and gloves before setting up sterile supplies.
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Only sterile items come in contact with the sterile field.
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Separate setups are used for procedures that involve both abdominal and perineal areas.
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Sterile items are inspected for proper processing, packaging, andpackage integrity immediately before presenting to the sterile field.
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Chemical indicator is inspected for color change.
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Heavy or sharp items are presented directly to the scrubbed team member or opened on a separate clean, dry surface.
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When opening items in peel pouches, the contents are not allowed to slide over the unsterile edges of the package.
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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.
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Rigid sterilization container lid is lifted up and toward the person opening the container and away from the container.
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Rigid sterilization container lid is inspected for integrity of the filter/valve/gasket.
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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.
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Sterile transfer devices (e.g. sterile vial spike, filter straw, plastic catheter) are used when transferring medications/solutions to sterile field.
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Stoppers are not removed from vials for the purpose of pouring medications (unless specifically designed for removal and pouring by the manufacturer).
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Sterile field is constantly monitored and not left unattended.
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Breaks in technique are immediately recognized and corrected.
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Comments:
5. Donning/Wearing Sterile Gowns & Gloves
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Hand hygiene is performed before entering the OR where sterile supplies are open.
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Sterile technique is used when donning/wearing sterile gown & gloves.
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Surgical hand scrub is performed before donning sterile attire.
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Sterile gown & gloves are donned in a sterile area away from main instrument table.
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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).
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Two pairs of surgical gloves are worn (preferred).
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Gloves are changed at appropriate times/intervals (e.g. suspected contamination, after direct contact with methylmethacrylate, visible defect, every 90-150 minutes).
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Comments:
6. Draping
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Sterile equipment is covered on the top, bottom, and sides with sterile barrier materials before being introduced to or brought over a sterile field.
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Gloved hands are shielded during draping.
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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.
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Drapes are placed from the surgical site to the peripheral areas.
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Drapes are not moved after being placed.
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Only the top surface of a sterile, draped area is considered sterile (items that fall below the sterile area are considered contaminated).
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Only iodophor-impregnated plastic adhesive incise drapes are used (for prevention of SSI).
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Comments:
7.Traffic Control/Moving within the Sterile Environment
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Scrubbed members remain close to the sterile field and touch only sterile areas or items.
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Scrubbed members do not leave the sterile field to retrieve items from the sterilizer.
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Scrubbed members keep their hands and arms above the waist level at all times.
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Scrubbed members do not fold their arms/place hands in axillary area.
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Scrubbed members avoid changing levels and are seated only when the entire procedure is performed at that level.
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Scrubbed members pass "back-to-back" or "face-to-face".
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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.
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Conversations in the presence of a sterile field are kept at a minimum.
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Number and movement of individuals involved in the procedure is kept at a minimum.
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Comments:
8. Major OR/Procedure Room Findings
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There were no other major findings in the OR/Procedure room.
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What were the additional findngs:
