Title Page

  • Conducted on

  • Prepared by

  • Location

Operating room/ Theater

  • Trash cans and linen hampers are emptied between each case (PE tubes exempt)

  • Trash and linen handled per policy

  • Hand hygiene products available

  • PPE available. Appropriate PPE used by staff

  • Sharps containers less than 3/4 full

  • Sharps containers secured properly

  • No paper supplies or patient care items stored under the sink

  • Safe medication preparation and administration practices are followed

  • Operating room, including Anesthesia Carts, are cleaned and disinfected between patients

  • Containers are securely closed for transport

  • All OR's are terminally cleaned at the end of the day

  • Sterilizers are tested daily according to manufacturer's instructions

  • Sterile processing and storage is done according to policy

  • Sterilization equipment is in good working condition

  • Preventive maintenance program is in place for sterilizers

  • Employee protection measures are implemented during sterile processing

  • Event related sterilization packaging is used

  • Surgical teams are observed during procedure and masks are securely in place prior to entering the OR

  • All head and facial hair is covered

  • Doors are completely closed and traffic flow followed


  • Trash cans and linen hampers not over filled. Trash and linen handled per policy

  • Glucose monitor clean and only one time use lancets are available

  • Bathrooms are clean

  • Crash Cart checked

  • Medication preparation area clean, organized and ready for use

  • Patient bays and carts are cleaned and disinfected according to procedure between each patient


  • Clean linens are in good condition

  • Clean linen is stored in a covered cart

  • Soiled linen bagged for transport

  • Soiled linen hampers have impervious liner or are emptied regularly

  • Soiled linen is removed from building on a regular schedule

  • Clean and dirty linen are kept separate

Hazardous/Biological waste

  • Door is labeled. Biohazard symbol on door. Emergency call button operational

  • Waste containers have correct emblem, are dated and bags are correctly tied and closed

  • Room is clean and uncluttered

  • OSHA compliant storage containers are used. Including sharps containers

  • Pick up for transfer is on a specified schedule

  • Containers are not overfilled

  • Appropriate waste manifests are maintained

  • Red bags are available in each regulated medical waste container

  • Door is labeled. Room is clean and uncluttered. Trash is in appropriate bag

Clean Storage areas - clean utility, equipment, sterile items, supplies, receiving.

  • Horizontal and vertical surfaces are clean. Area is clean and uncluttered

  • Items are clean and ready to use

  • Supplies are at least 40 inches from the ceiling and 20 inches from the floor

  • No patient care items or paper products are stored under sinks

Medication Management

  • Single dose vials/syringes are used whenever possible

  • Sharps safety devices are in use and being used accordingly

  • Syringes are not used between patients (even if the needle has been changed). Changing the needle for such a purpose is unacceptable

  • Multi-dose vials are avoided when possible but when used between patients are not stored in the “immediate patient care” environment

  • After penetration of the rubber stopper, multi-dose vials require a beyond use date of 28 days unless the manufacturer’s expiration date will be reached before 28 days or the product labeling (package insert) states otherwise

  • Inspect vials and medication syringes for any signs of contamination or tampering

  • A new syringe and needle is used when accessing a vial

  • All medication and flush syringes are appropriately labeled

  • Controlled medications are securely stored (locked) when not overseen by anesthesia

  • staff

  • Non-controlled medications may be left unlocked in a secure area in the immediate perioperative period. Individual facilities are to define the secure area and the term immediate perioperative period

  • Medication storage and preparation area is maintained as a clean space

  • Used medications are not stored back on the clean preparation area

  • Vials/syringes should not be stored or transported in clothing or pockets except when an organization specifically allows for this for the purposes of facilitating premedication or to have rescue meds readily available when transporting a patient

  • Diaphragms of vials are cleansed using friction and sterile 70% isopropyl alcohol, ethyl alcohol or other approved antiseptic swab and allowed to dry prior to accessing

  • Ampules are disinfected and allowed to dry prior to opening. Filter needles are used when accessing contents

  • Aseptic technique is used when handling and administering medications

  • Process to prevent medication diversion in place

  • Are medications and sharps secured and locked?

  • Are medication rooms and anesthesia carts locked when unattended?

  • Are needles and syringes locked when not attended?

  • Respiratory care procedures/equipment

  • Breathing circuit – use filter with efficiency rating of 95% for particle micron sizes of 0.3micron

  • IV bags or bottles are not to be used as a common source (e.g. saline flushes) for multiple patients


  • Proper disinfection with hospital-approved product at end of case includes but is not limited to: anesthesia med/supply cart, anesthesia machine (knobs, surfaces, cords, keyboard, monitor, Adjustable Pressure Limiting (APL) valve), IV pole, laryngoscope handle)

  • Single patient use items are discarded at the end of each case (e.g. circuits, airway bags, suction tubing)

  • Stethoscopes are disinfected per hospital P&P

  • Are anesthesia staff responsible for cleaning and high-level disinfection and/or sterilization of any reusable equipment? If yes, competencies in place and all quality control measures performed and documented

Medical Stores

  • There is a written policy and procedures for the medical storage

  • Medical storage areas are of adequate capacity, regularly cleaned, secured and away from contamination, air vents and direct sunlight

  • Medical storage areas have controlled ventilation with adjusted temperature and humidity (temperature ranges from 22 °C to 24 °C / relative humidity up to 70%)

  • Storage shelves are at least, 40 cm from the ceiling, 20 cm from the floor, and 5 cm from the wall

  • Storage shelves are made of easily cleanable material, e.g., fenestrated stainless steel, Aluminium or hard plastic

  • Sterile and clean items are completely separated from personal items, foods and drinks

  • No Items are kept in the original shipping boxes, especially in the clinical areas

  • There is a written policy and procedures for IC considerations during demolition, renovation, and construction projects

  • IPC team is involved prior to, during, and after any construction, demolition, and renovation project (Planning, ICRA, IC permit, continuous follow - up and authority to stop the project)

  • IPC measures are followed during the construction, demolition, and renovation projects by using infection control risk assessment (ICRA)

  • According to MOH regulations, no reuse for single use items

additional findings:

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