Inspection

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

PACU

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

Linen

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

Disinfection

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:

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.