Is gross tissue removed and is enzymatic solution applied at point of use?
Are hinged instruments opened prior to use of enzymatic solution?
Are Standard Precautions used at all stages of handling used items? (PPE is used)
Are written procedures for handling of used equipment available?
Are all single-use items discarded at point of use?
Are collection containers puncture resistant, leak proof and lidded?
Is the container / cart cleaned at the end of each collection round?
Are all instruments that have been unwrapped for use considered contaminated whether used or not and subjected to full cleaning process?
Are there written procedures for handling specialized equipment? (Power, delicate, etc.)
Appropriate flow from dirty to clean
PPE appropriately utilized
Three sink configuration used for cleaning instruments
Water temperature monitored per disinfectant IFUs
Low foaming disinfectant utilized per manufacturer recommendation
Brushing of instruments takes place under the water
Appropriate size brushes are utilized according to the instruments IFU
Brushes are in good condition
Brushes are washed daily and replaced when needed
Ultrasonic quality testing completed and documented daily
Ultrasonic water changed per policy
Ultrasonic degassed according to IFU
Washer in good working condition & serviced according to manufacturer IFU
TOSTI test performed on each level of washer daily & documented
Washing descaling performed according to manufacturer IFU
No trash located in the washer
No solid rigid containers utilized in the washer
All hinged instruments in open position when placed in the washer
Quality testing performed on cart washer according to manufacturer IFU
Separate sink available for hand washing
Pass through window remains closed then not in use
Eye wash station available on a clean sink
Eye wash log current
Area cleaned daily when department in use
Dedicated cart utilized for decontamination area of processing department
Decontamination area clean with minimal dust present
No Stained ceiling tiles
All sprinkler free of dust with escusions present and intact
Daily the floor of the sterilizer is checked and free of debris, chamber drain and filters are clear, recording devices are functioning correctly and the door gasket is undamaged.
Maintenance on sterilizers are completed and documented according to manufacturer IFU
Leak test performed on each sterilizer weekly
Bowie-Dick performed daily in each sterilizer and documented
Biological indicator test completed daily
Biological indicator placed with every sterilization load
Implants are never released until confirmation of passed biological indicator
Instruments sets weigh less than 25Ibs
When recommissioning and performance requalification is performed the process is documented and a copy filed in the facility.
Appropriate PPE worn while in the department
Staff have access to manufacturer IFU
Manufacturer IFU are followed for each instrument
Instruments with hinges or ratchets remain open or unlocked during sterilization.
Multi part instruments are disassembled prior to packaging to permit effective sterilization.
Basin sets are packed so all openings face the same direction.
The color change of the sterilizing indicator tape following exposure is distinct and uniform and markedly different to the unprocessed tape.
Cleaning agents are not utilized in the prep and pack area
Brushes are not utilized in the prep ad pack area
Class V indicator placed in the most challenging area
Staff is able to state the acceptable temperature setting for drying cabinet and actions taken if out of range.
Bowls/basins are tilted on edge in a draining position so that only minimal resistance to removal of air, the passage of steam and condensate will be met.
Packs of towels are loaded in vertical layers to allow air to be removed rapidly from packs.
Items are loaded within boundaries of the sterilizer cart so that they do not touch the chamber walls or fall from the cart.
Flexible packaging materials are loaded on edge.
Sterilizer carts are loosely loaded to capacity with only a single layer of wrapped packs placed on each shelf.
The department has clear written procedures on the loading of sterilizers and all staff performing this task have had the formal training to do so.
On completion the load is visually inspected to ensure it is dry and that sterilizing indicators have made the required color change.
When removing of the load from the sterilizer the operator checks printouts and signs that the parameters have been met.
The load is quarantined and the supervisor is notified immediately if any deviation from the parameters is detected.
Sterilizer carts containing cooling items are kept away from high activity areas.
Cooling items are never placed onto solid surfaces as condensation may result.
Items that have been dropped on the floor, placed onto a dirty surface, have torn wrap or broken seals, or are wet are considered non sterile and reprocessed.
The person in charge of the sterile processing department is responsible / involved in the selection process prior to the purchase of instruments.
Manufacturers recommendations are available for processing equipment and instruments.
All staff working in the sterile processing department has had education and training on the correct handling of instruments.
Magnification available to assist with visual inspection
Instrument repairs are only performed by a qualified person.
Any instrument that appears defective is cleaned, dried and sterilized prior to being sent for repairs.
Lumens, grooves and articulations are free of debris and stylets are passed through lumens.
The tips of instruments do not have hooks or snags and approximate accurately.
Prep & pack area with positive air pressure
Humidity within range (30-60%, AAMI)
No dirty equipment found in prep & pack area
No Food in department
Area cleaned Daily with department in use
Area clean with minimal dust on horizontal surfaces
Floor clean and free of debris
No stained ceiling tiles
Sprinklers dust free with eschusions in place and in working order
Sterile Supplies stored at least 2 inches from the outside wall, 18 inches below the ceiling (or level of the sprinkler head), and 8-10 inches above the floor to prevent contamination from floor dust and cleaning.
Bottom storage shelves of supply cart are solid to prevent contamination from floor dust and cleaning
Is event related sterility assurance policy applied?
Storage area is clean, dry adequate and integrity of packaging maintained.
Heavy wrapped trays are not stacked
Corrugated boxes not present
Inappropriate or unnecessary equipment and supplies are not present in the area