Information
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Document No.
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Audit Title
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
I. Operating/Procedure Room Environment
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Operating/procedure room, halls, equipment/carts, vents appear clean, dust free, uncluttered. Floors clean and free of debris/dust.
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Operating/procedure room facility in good repair (e.g., no holes in walls, floors or ceiling)
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Solid ceiling; no tiles
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Interim EVS cleaning performed directionally, top to bottom
II. Sterile Supplies and Equipment
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Are non-essential items stored uncovered in operating rooms?
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All equipment clean and OR bed mattress pads/arm boards intact?
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Flexible scopes
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Sterile supplies protected from contamination/dust?
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No expired supplies
III. Room Procedure Observation
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Is floor mopped in between cases?
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Doors closed, not propped open; traffic in and out of room kept to minimum during case
IV. Perioperative Patient Care
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Pre-op antibiotic given by anesthesia personnel within 60 minutes prior to incision (Note: 120 minutes for Vancomycin /Fluoquinolines)
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IV injection ports swabbed prior to access
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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)
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Pre-op skin prep: was op-site cleaned prior to scrub? <br>
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Dual agent prep used (i.e., Chloraprep or Duraprep)
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Is application technique appropriate for product used? [Side to side (Chloraprep)] [In concentric circles, from middle out to periphery (Betadine)]
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Perineal area prepped and covered with impervious drape?
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Is operative site allowed to air dry prior to incision? How long did site dry prior to incision?_________________
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Is operative site dried with a towel or 4x4s prior to incision?
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Is adhesive incise drape used?
V. Attire (for anyone entering semi-restricted and restricted surgical site areas)
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Surgical caps/hood cover all hair
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Nursing
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Anesthesia
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Surgeons
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Body hair (ex: chest, facial) fully covered
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Do any operating/procedure room staff members appear to have long or artificial fingernails?
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Dress code followed: No rings; other jewelry (e.g. watches, earrings, bracelets, necklaces, piercing) should be removed or totally confined within scrub attire
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Dress code followed: Shirts of scrub suit tucked in or close fitting
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Dress code followed: All non-scrubbed personnel wearing long sleeved jackets (hospital approved) that are buttoned or snapped
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Dress code followed: No fanny packs, backpacks, totes
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Dress code followed: Clean (not visibly wet or soiled) operating/procedure room scrub suit
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Dress code followed: Undergarments completely covered, no turtlenecks or fleece
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Dress code followed: Shoe covers worn when dedicated shoe ware not in use.
VI. Sterile Field
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Mask covers nose and mouth and is tied securely
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Mask in place when entering OR with open sterile packs and in sterile core
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Sterile items left open no more than 60 minutes prior to patient entering room and should be constantly monitored during that time period
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Scrubbed persons maintain sterility of sterile gown, gloves, supplies (e.g., while waiting for procedures to be done such as X-Rays?)
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Chemical indicators must be checked when instruments are opened, before they are placed on the sterile field
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Items introduced into sterile field are opened, dispensed, and transferred by methods to maintain sterility/integrity
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Items/devices dropped below level of the operating/procedure room table are considered contaminated
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Is drape between anesthesia and pt. above the level of anesthesiologist’s nose/mouth? Does anesthesia lean over drape during procedure?
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Surgical equip (e.g. cables, tubing) secured to sterile field with non-perforating devices
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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
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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
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Drainage bags (e.g., foley) kept off the floor
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Aseptic practice used for IV tubing, fluids, medications – injection ports swabbed prior to access
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Sterile equip. – IV solution/tubing assembled immediately prior to use
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Aseptic practice used for all invasive procedures (e.g., epidurals, blocks, IV insertion)
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Was antibiotic infusion mentioned/checked prior to incision?
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Was antibiotic infusion repeated if surgery is longer than 4 hours?
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Anesthesia cart appears clean; hand sanitizer readily available
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Re-usable personal equipment (e.g., stethoscope) cleaned between cases
VIII. Medications/Solutions
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Are medications and solutions: single-dose or multi-dose? What solutions/medications are multi-dose?___________________________
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Are any medications or solutions expired?
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Is the wound irrigated? If yes, list solution used for irrigations.
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Are topical medications one time use?
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Are any solutions mixed in the operating/procedure room? If yes, list:_________________________________
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Manufacturer's IFU (solution, length of soak time) followed for reconstitutions?
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Are any containers refilled? If yes, list:_______________________________________________________
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Are any solutions supplied or used as a spray?
IX. OSHA/Bloodborne Pathogen Standard
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Appropriate eye protection used
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Sharps containers at point of use, secured from tipping, no more than ¾ full
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Sharps safety devices utilized where available
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Biohazard room labeled and locked
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Hoppers & biohazard containers accessible in soiled utility
X. General Infection Prevention and Control
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Do members of the surgical team appear to have upper respiratory infection (e.g., cough, sneezing)?
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Do any operating/procedure room staff appear to have hand/forearms/skin/fingernail open lesions or infections?
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Was conversation in sterile field limited to only necessary conversation?
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Sterile team removes gloves and washes hands at end of case
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Were gloves changed between dirty and clean procedures?
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Was hand hygiene performed when gloves changed?
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Is a hand antisepsis product available?
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Clean, sterile, and soiled items are kept separate
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Used sterile instruments pre-cleaned with enzymatic cleaner/equipment transported to CSR for decontamination and sterilization
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Were instruments transported in a closed container?
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Was the container labeled with the chemical used for the instruments?
XI. Sterilization
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Are instrument trays checked by nurse for breaks prior to placing on sterile field?
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Are biologicals performed and within normal limits for sterilizers?
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Do processes appear efficient in SPD with items/areas tidy and well labeled?
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Are instruments pre-cleaned or soaked soon after use?
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Were instruments sterilized using IUSS delivered to sterile field without contamination?
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Water was not splashed on the sterile field when instruments sterilized using IUSS were delivered?
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Were items sterilized using immediate-use steam sterilization? If yes, list reason for using IUSS: __________________________________
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Item that was sterilized using IUSS was not contaminated by circulating nurse?
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Was IFU followed and all required documentation completed?
XII. HVAC Systems (if not optimal, action plan required)
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Room humidity between 30-60%? Document humidity:__________________
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Room temperature between 68-73 degrees? Document temperature: ________________
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Air exchanges/hour at least 15/hour or between 20-25? Document AE/H: _________________
XIII. Hand Scrub (observe one individual scrubbing)
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Physician, Nurse, Tech, or SA
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Product used: _________________________________________
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Scrub brush used with product
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Does the healthcare worker clean under his/her fingernails?
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Is scrub accomplished from hand to forearm to elbow?
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Does the surgical scrub last 3-5 minutes?
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When the scrub is finished, are fingers held up so water runs down toward elbows?
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If waterless product is used as the first scrub of the day, is it a water aided scrub?
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If waterless product is used, does the staff member apply product to hand and then up arms to elbow?
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Hand scrub products are not "topped off?"
XIV. Refrigerator / Freezer Monitoring and Tissue Tracking
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Temperature Log or Temp Track complete
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Notification if temperature is out of range
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Contingency plan
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Separate refrigerators for tissue/medications
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Tissue is temperature monitored/documented from time delivered to storage
Additional Comments
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Are there any additional findings or comments?
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Surveyor's Signature
