• Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

  • Select date

Surgical Attire

  • Staff changed into scrubs at the hospital

  • Top is secured at waist, tucked in or close to body

  • Al hair is covered

  • No visible jewelry worn by scrubbed and non-scrubbed staff

  • Mask is worn by (secured with both ties) in the presence of open sterile items and equipment

  • Cover gowns/jackets are worn and secured to prevent inadvertent contamination while walking past sterile field

  • Dedicated shoes or shoe covers are worn

Sterile Technique

  • Sterile field is prepared close to time of surgery <1 hour

  • Sterile items are transported in covered or enclosed cases/carts

  • Sterile packages are inspected for punctures, tears, and expiration dates

  • Sterile field is maintained troughout the procedure with traffic patterns established with a minimum of one foot perimeter respected by the unsterile personnel

  • Sterile items are presented to scrubbed person or placed securely on field

  • Liquids are poured only once, without splashing, and the remainder is discarded

  • Draping is accomplished in a sterile manner:<br> * Draping is performed by a minimum of two people<br> * Hands are "cuffed" while presenting drapes to unsterile personnel<br> * Anesthesia screen is not dropped prior to placement<br> * Drapes are not lifted or moved after placement

  • Items are flashed sterilized only in an emergency situation and a closed container is used or transport to the sterile field

Surgical Hand Scrub

  • Scrub is performed according to manufacturer's directions and aseptic technique

  • Scrubbed personnel do not contaminate themselves while gowning and gloving

Time Out

  • Observe Universal Protocol "Time Out"

  • Site marked prior to entry into OR suite (in pre-op holding area)

  • Circulator calls "TIME OUT"

  • Circulator checks patient's ID bracelet- patient identificiation

  • Circulator states the correct site

  • Circulator reads aloud the surgical procedure to be done

  • Outpatient chart review- H&P reviewed and documented

Skin Prep

  • Hair is removed using clippers

  • Skin prep is performed according to manufacturer's directions and aspectic technique

  • Type of Prep used

  • Sufficient drying time is allowed prior to draping


  • Traffic in and out of the room is kept to essential personnel/tasks

  • The traffic pattern during the case avoids the sterile field whenever possible

Environmental Cleaning

  • Horizontal surfaces are free of dust and organic debris

  • After procedure, reusable patient items such as straps are cleaned between uses

  • After procedure, visibly soiled areas of the floor (three to four feet perimeter around the bed) is mopped free of all blood and debris

  • OR doors are closed between cases

  • Scrub tech removes excess tissue from instruments

  • Enzymatic spray prior to delivery to CS

  • Operating room's environmental temperature and humidity temperature range 68-73 degrees and humidity range 30-60%. Staff takes and documents corrective action if temperature and humidity ranges are not met

  • Linen, equipment and supplies are properly stored within the operating room and OR department, including appropriate covers and storage practices to minimize the potential for dust and contamination


  • Medications are labeled appropriately when in use

  • Safety devices are used whenever possible

  • Refrigerators are specific for medications, staff foods, etc.

  • Sharps are removed and disposed of appropriately at the completion of each case

  • Sharps containers are accessible, secured to wall/counter and emptied when the "full" line is reached

  • Unused medications/fluids are disposed of at the end of each case

  • Fluid warmers are checked for approved temperature ranges each day the OR is functioning. If the OR is closed it is documented on the warmer log.

  • Dirty / clean equipment is stored separately

  • Glass is disposed of in rigid sharps containers

  • Biohazard waste is labeled and covered

  • Cleaning supplies are labeled

  • Approved cleaning supplies

Cleaned / Soiled Areas

  • Soiled linens are placed in designated covered hampers

  • Under sink storage is limited to disinfectants / cleaners

  • No eating or drinking in patient care area

  • Clean equipment is labeled clean / clean label removed for used equipment

  • All sterile supplies are dry with intact packaging, not stored on the floor

  • Low storage areas must have solid surface shelving

  • Storage of sterile supplies is 8-10" above the floor and 2" away from exterior walls

  • Ice scoop is not stored in the ice machine

  • Staff know where to find and how to access infection prevention policies and procedures

  • CDC isolation guidelines are available on isolation carts or other designated areas in the department

  • Staff are aware of when to use Airborne isolation and which rooms are negative pressure

  • Staff are knowledgable about blood spill protocol

  • Staff know the kill time for disinfectants used

  • Staff have access to and are familiar with the MDRO list

  • Staff have knowledge of hand hygiene requirements and practice these requirements

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.