IP EOC OR: Pre-Opening

• Location
  Address

• Document No.

• Audit Title

• Conducted on

  Date

• Prepared by

I. Operating/Procedure Room Environment

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

  Compliant

  Non-compliant

  N/A

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

  Compliant

  Non-compliant

  N/A

• Solid ceiling; no tiles

  Compliant

  Non-compliant

  N/A

• Interim EVS cleaning performed directionally, top to bottom

  Compliant

  Non-compliant

  N/A

II. Sterile Supplies and Equipment

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

  Compliant

  Non-compliant

  N/A

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

  Compliant

  Non-compliant

  N/A

• Flexible scopes

  Compliant

  Non-compliant

  N/A

• Sterile supplies protected from contamination/dust?

  Compliant

  Non-compliant

  N/A

• No expired supplies

  Compliant

  Non-compliant

  N/A

III. Room Procedure Observation

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

  Compliant

  Non-compliant

  N/A

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

• Surgical caps/hood cover all hair

  Compliant

  Non-compliant

  N/A

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

  Compliant

  Non-compliant

  N/A

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

  Compliant

  Non-compliant

  N/A

VII. Anesthesiology

• Sterile equip. – No IV solution/tubing seen assembled ahead of time (prep only at start of case)

  Compliant

  Non-compliant

  N/A

VIII. Medications/Solutions

• Are any medications or solutions expired?

  Compliant

  Non-compliant

  N/A

IX. OSHA/Bloodborne Pathogen Standard

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

  Compliant

  Non-compliant

  N/A

• Biohazard room labeled and locked

  Compliant

  Non-compliant

  N/A

• Hoppers & biohazard containers accessible in soiled utility

  Compliant

  Non-compliant

  N/A

X. General Infection Prevention and Control

• Hand antisepsis product(s) available?

  Compliant

  Non-compliant

  N/A

• Clean, sterile, and soiled items are kept separate

  Compliant

  Non-compliant

  N/A

XI. Sterilization

• Are biologicals performed and within normal limits for sterilizers?

  Compliant

  Non-compliant

  N/A

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

  Compliant

  Non-compliant

  N/A

• Staff know where to locate equip/instrument MIFUs

  Compliant

  Non-compliant

  N/A

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

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

  Compliant

  Non-compliant

  N/A

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

  Compliant

  Non-compliant

  N/A

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

  Compliant

  Non-compliant

  N/A

XIV. Refrigerator / Freezer Monitoring and Tissue Tracking

• Temperature Log or Temp Track complete

  Compliant

  Non-compliant

  N/A

• Separate refrigerators for tissue/medications

  Compliant

  Non-compliant

  N/A

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

  Compliant

  Non-compliant

  N/A

Additional Findings

• Compliant

  Non-compliant

  N/A

• Compliant

  Non-compliant

  N/A