• Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

I. Operating/Procedure Room Environment

  • Operating/procedure room, halls, equipment/carts, vents appear clean, dust free, uncluttered. Floors clean and free of debris/dust.

  • Operating/procedure room facility in good repair (e.g., no holes in walls, floors or ceiling)

  • Solid ceiling; no tiles

  • Interim EVS cleaning performed directionally, top to bottom

II. Sterile Supplies and Equipment

  • Are non-essential items stored uncovered in operating rooms?

  • All equipment clean and OR bed mattress pads/arm boards intact?

  • Flexible scopes

  • Sterile supplies protected from contamination/dust?

  • No expired supplies

III. Room Procedure Observation

  • Is floor mopped in between cases?

  • Doors closed, not propped open; traffic in and out of room kept to minimum during case

IV. Perioperative Patient Care

  • Pre-op antibiotic given by anesthesia personnel within 60 minutes prior to incision (Note: 120 minutes for Vancomycin /Fluoquinolines)

  • IV injection ports swabbed prior to access

  • Hair removal performed before entering operating/procedure room (planned hair removal only; occasionally additional hair must be clipped or done in the operating/procedure room)

  • Pre-op skin prep: was op-site cleaned prior to scrub? <br>

  • Dual agent prep used (i.e., Chloraprep or Duraprep)

  • Is application technique appropriate for product used? [Side to side (Chloraprep)] [In concentric circles, from middle out to periphery (Betadine)]

  • Perineal area prepped and covered with impervious drape?

  • Is operative site allowed to air dry prior to incision? How long did site dry prior to incision?_________________

  • Is operative site dried with a towel or 4x4s prior to incision?

  • Is adhesive incise drape used?

V. Attire (for anyone entering semi-restricted and restricted surgical site areas)

  • Surgical caps/hood cover all hair

  • Nursing

  • Anesthesia

  • Surgeons

  • Body hair (ex: chest, facial) fully covered

  • Do any operating/procedure room staff members appear to have long or artificial fingernails?

  • Dress code followed: No rings; other jewelry (e.g. watches, earrings, bracelets, necklaces, piercing) should be removed or totally confined within scrub attire

  • Dress code followed: Shirts of scrub suit tucked in or close fitting

  • Dress code followed: All non-scrubbed personnel wearing long sleeved jackets (hospital approved) that are buttoned or snapped

  • Dress code followed: No fanny packs, backpacks, totes

  • Dress code followed: Clean (not visibly wet or soiled) operating/procedure room scrub suit

  • Dress code followed: Undergarments completely covered, no turtlenecks or fleece

  • Dress code followed: Shoe covers worn when dedicated shoe ware not in use.

VI. Sterile Field

  • Mask covers nose and mouth and is tied securely

  • Mask in place when entering OR with open sterile packs and in sterile core

  • Sterile items left open no more than 60 minutes prior to patient entering room and should be constantly monitored during that time period

  • Scrubbed persons maintain sterility of sterile gown, gloves, supplies (e.g., while waiting for procedures to be done such as X-Rays?)

  • Chemical indicators must be checked when instruments are opened, before they are placed on the sterile field

  • Items introduced into sterile field are opened, dispensed, and transferred by methods to maintain sterility/integrity

  • Items/devices dropped below level of the operating/procedure room table are considered contaminated

  • Is drape between anesthesia and pt. above the level of anesthesiologist’s nose/mouth? Does anesthesia lean over drape during procedure?

  • Surgical equip (e.g. cables, tubing) secured to sterile field with non-perforating devices

  • Nonsterile equip. (mayo stands, C arms) should be covered w/sterile barrier materials; only sterile items touch sterile surfaces; sterile barrier material should be applied to any equip adjacent to the sterile field

  • All personnel moving in/around sterile field do so in manner to maintain sterility, for example:<br>a. Staff do not turn back to sterile field, hands above waist<br>b. Scrubbed personnel pass front to front or back to back<br>c. Separation of sterile team from non-sterile team maintained<br>d. Unscrubbed personnel do not pass between two sterile fields

VII. Anesthesiology

  • Drainage bags (e.g., foley) kept off the floor

  • Aseptic practice used for IV tubing, fluids, medications – injection ports swabbed prior to access

  • Sterile equip. – IV solution/tubing assembled immediately prior to use

  • Aseptic practice used for all invasive procedures (e.g., epidurals, blocks, IV insertion)

  • Was antibiotic infusion mentioned/checked prior to incision?

  • Was antibiotic infusion repeated if surgery is longer than 4 hours?

  • Anesthesia cart appears clean; hand sanitizer readily available

  • Re-usable personal equipment (e.g., stethoscope) cleaned between cases

VIII. Medications/Solutions

  • Are medications and solutions: single-dose or multi-dose? What solutions/medications are multi-dose?___________________________

  • Are any medications or solutions expired?

  • Is the wound irrigated? If yes, list solution used for irrigations.

  • Are topical medications one time use?

  • Are any solutions mixed in the operating/procedure room? If yes, list:_________________________________

  • Manufacturer's IFU (solution, length of soak time) followed for reconstitutions?

  • Are any containers refilled? If yes, list:_______________________________________________________

  • Are any solutions supplied or used as a spray?

IX. OSHA/Bloodborne Pathogen Standard

  • Appropriate eye protection used

  • Sharps containers at point of use, secured from tipping, no more than ¾ full

  • Sharps safety devices utilized where available

  • Biohazard room labeled and locked

  • Hoppers & biohazard containers accessible in soiled utility

X. General Infection Prevention and Control

  • Do members of the surgical team appear to have upper respiratory infection (e.g., cough, sneezing)?

  • Do any operating/procedure room staff appear to have hand/forearms/skin/fingernail open lesions or infections?

  • Was conversation in sterile field limited to only necessary conversation?

  • Sterile team removes gloves and washes hands at end of case

  • Were gloves changed between dirty and clean procedures?

  • Was hand hygiene performed when gloves changed?

  • Is a hand antisepsis product available?

  • Clean, sterile, and soiled items are kept separate

  • Used sterile instruments pre-cleaned with enzymatic cleaner/equipment transported to CSR for decontamination and sterilization

  • Were instruments transported in a closed container?

  • Was the container labeled with the chemical used for the instruments?

XI. Sterilization

  • Are instrument trays checked by nurse for breaks prior to placing on sterile field?

  • Are biologicals performed and within normal limits for sterilizers?

  • Do processes appear efficient in SPD with items/areas tidy and well labeled?

  • Are instruments pre-cleaned or soaked soon after use?

  • Were instruments sterilized using IUSS delivered to sterile field without contamination?

  • Water was not splashed on the sterile field when instruments sterilized using IUSS were delivered?

  • Were items sterilized using immediate-use steam sterilization? If yes, list reason for using IUSS: __________________________________

  • Item that was sterilized using IUSS was not contaminated by circulating nurse?

  • Was IFU followed and all required documentation completed?

XII. HVAC Systems (if not optimal, action plan required)

  • Room humidity between 30-60%? Document humidity:__________________

  • Room temperature between 68-73 degrees? Document temperature: ________________

  • Air exchanges/hour at least 15/hour or between 20-25? Document AE/H: _________________

XIII. Hand Scrub (observe one individual scrubbing)

  • Physician, Nurse, Tech, or SA

  • Product used: _________________________________________

  • Scrub brush used with product

  • Does the healthcare worker clean under his/her fingernails?

  • Is scrub accomplished from hand to forearm to elbow?

  • Does the surgical scrub last 3-5 minutes?

  • When the scrub is finished, are fingers held up so water runs down toward elbows?

  • If waterless product is used as the first scrub of the day, is it a water aided scrub?

  • If waterless product is used, does the staff member apply product to hand and then up arms to elbow?

  • Hand scrub products are not "topped off?"

XIV. Refrigerator / Freezer Monitoring and Tissue Tracking

  • Temperature Log or Temp Track complete

  • Notification if temperature is out of range

  • Contingency plan

  • Separate refrigerators for tissue/medications

  • Tissue is temperature monitored/documented from time delivered to storage

Additional Comments

  • Are there any additional findings or comments?

  • Surveyor's Signature

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