Title Page

  • Name of Technician

  • Tray Name

  • Specialty

  • Sterilization Method

  • Conducted on

  • Prepared by

Outer Packaging

  • What type of packaging?

  • Are the locks intact?

  • Count sheet attached to handles?

  • Are there dents on the outside container bottom or lid?

  • Does the parameters match the sterilization?

  • Is the container lid gasket intact?

  • Is the container filter present?

  • Is the filter ring functioning appropriately? (Does not spin)

  • Is the filter integrity intact? (No holes or folds)

  • Is moisture present at the bottom of container?

  • Is the outer wrap intact?

  • Did the sterilization tape change to the appropriate color?

  • Is the sterilization tape overlapped?

  • Does the tray have the appropriate label?

  • Does the parameters match the sterilization tape?

  • Is the trauma wrapped according to standard envelope wrap?

  • Are the flaps folded correctly and not tucked under the tray?

  • Is there moisture present?

  • Are there visible Stains or water spots on package?

  • Is the chemical integrator visible?

  • Is the integrator pass or fail?

  • Does the label match the parameter?

  • Is there a break in package integrity?

  • Was there double pouching performed?

  • Does the inside pouch fit appropriately?

  • Is a Load Sticker present?

Interior Inspection

  • Is there a class 5 chemical integrator present?

  • What is the class 5 chemical integrator result?

  • Are Tip Protectors or Duraholders/Pouches present? (If required)

  • Are there cords and/or cables present?

  • Are the cords/cables coiled correctly? (Loosely, no tight coils or sharp bends)

  • Is there Bioburden/Biofilm present?

  • How many instruments were contaminated?

  • Which instruments were contaminated?

  • Is there Instrument Tape present?

  • Is the instrument tape intact?

  • How many instruments had tape on them?

  • Which instruments had tape on them?

  • Is there instrument etching present?

  • How many instruments had etching?

  • Which instruments had etching?

  • Are Nicks, Dents, Burs, Damage, present?

  • How many instruments were damaged?

  • Which instruments were damaged?

  • Does this tray have cutting instruments? (Scissors, Rongeurs, Kerrisons, Curettes, Osteotomes)

  • Results of Sharpness Test

  • Which instruments failed the sharpness test?

  • How many instruments failed the sharpness test?

  • Does this tray have insulated instruments? (Insulated GYN, Bipolars, Laparoscopic)

  • What are the results of the insulation scanning test?

  • Which instruments failed the insulation test?

  • How many instruments failed insulation test?

  • Does the count sheet have all of the required data? (Manufacturer, Description, Catalog Number)

  • Do the instruments match the count sheet?

  • Does the number of instruments match the required number on the count sheet?

  • What is the required number of instruments?

  • What is the ACTUAL number of instruments in the tray?

  • How organized was the tray?

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