CSR Tracer Tool

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Location
  Address

Environment

• 1. Correct pressure relations. ( Negative to the hallways, positive in clean room)

  Yes

  No

  N/A

• 2. Temperature and Humidity Log filled out and within normal ranges.

  Yes

  No

  N/A

• 3. Door closed to hallway.

  Yes

  No

  N/A

• 4. Eye wash stations are checked on a weekly basis and documented.

  Yes

  No

  N/A

• 5. Floors are clean and free of clutter.

  Yes

  No

  N/A

Decontamination Room

• 1. Physical separation from the Clean Room.

  Yes

  No

  N/A

• 2. Separate sinks for washing instruments and for hygiene.

  Yes

  No

  N/A

• 3. PPE supplies present in decontamination room.

  Yes

  No

  N/A

• 4. Source of treated water present. (deionized, reverse osmosis, filtered)

  Yes

  No

  N/A

• 5. Cleaning Chemicals are not expired.

  Yes

  No

  N/A

• 6. Solution temp and soak time is monitored and documented.

  Yes

  No

  N/A

• 7. Pre-cleaning appears to be occurring before instruments are brought to decontamination.

  Yes

  No

  N/A

• 8. No "clean" items/equipment present in the decontamination room to prevent cross contamination.

  Yes

  No

  N/A

PPE requirements

• 1. A fluid resistant gown with sleeves is worn.

  Yes

  No

  N/A

• 2. Gloves, a mask and eye protection is worn.

  Yes

  No

  N/A

• 3. Shoe covers or boots designed for use as PPE being used.

  Yes

  No

  N/A

• 4. Hand hygiene performed after PPE is removed.

  Yes

  No

  N/A

Clean Room

• 1. Terminal Cleaning performed at the end of the day per policy.

  Yes

  No

  N/A

• 2. IFUs for sterilizers are being followed for operation and routine maintenance is being performed.

  Yes

  No

  N/A

• 3. Lot number and expiration date are being captured for the Bowie Dicks.

  Yes

  No

  N/A

• 4. Immediate use steam sterilization is being monitored.

  Yes

  No

  N/A

• 5. Test strips or indicators are dated correctly and labeled with expiration date.

  Yes

  No

  N/A

Packaging and Storage

• 1. All sterile peel packs are labeled with a sticker from CSR which identifies the load number and date that the peel pack was sterilized.

  Yes

  No

  N/A

EOC

• 1. All cylinders (oxygen, other compressed gas) are secured

  Yes

  No

  N/A

• 2. Fire extinguishers not obstructed from easy access

  Yes

  No

  N/A

• 3. No electrical panels are blocked

  Yes

  No

  N/A

• 4. hospital furnishings/equipment are kept in good repair

  Yes

  No

  N/A

• 5. Countertops/doors are in good condition with no chipping to laminate

  Yes

  No

  N/A

• 6. No supplies stored under sinks

  Yes

  No

  N/A

• 7. Paper is not present on fire-rated doors

  Yes

  No

  N/A

• 8. Maintains the integrity of egress throughout the unit

  Yes

  No

  N/A

• 9. No space heaters present

  Yes

  No

  N/A

• 10. There is at least 18" of open space maintained below a sprinkler deflector to the top of storage

  Yes

  No

  N/A