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
Are non-essential items stored uncovered in operating rooms?
All equipment clean and OR bed mattress pads/arm boards intact?
Sterile supplies protected from contamination/dust?
No expired supplies
Is floor mopped in between cases?
Doors closed, not propped open; traffic in and out of room kept to minimum during case
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?
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?
Surgical caps/hood cover all hair
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.
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:
a. Staff do not turn back to sterile field, hands above waist
b. Scrubbed personnel pass front to front or back to back
c. Separation of sterile team from non-sterile team maintained
d. Unscrubbed personnel do not pass between two sterile fields
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
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?
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
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?
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?
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: _________________
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?"
Temperature Log or Temp Track complete
Notification if temperature is out of range
Separate refrigerators for tissue/medications
Tissue is temperature monitored/documented from time delivered to storage
Are there any additional findings or comments?