OR #





Circulating RN

Scrub Tech(s):

Relief staff:


Time out according to policy

Abx timing addressed by Surgeon

Surgical Attire (every person)

Top is secure or close to the body

All hair is covered

Mask is worn & secure in the presence of open sterile items & equipment

Sterile Technique

Sterile field is prepared close to the time of surgery

Sterilized items at transported in covered or enclosed cases/carts

Sterile field is maintained throughout procedure, traffic pattern 1 foot perimeter respected

Sterile persons do not turn their back to the field or supplies

Sterile items are presented to scrubbed person or placed securely in field

Liquids are poured once, w/o splashing, and remainder discarded. No recapping

Draping is accomplished in sterile manner; hands are cuffed whole presenting drapes to unsterile personnel, anesthesia screen is not dropped prior to placement, drapes are not lifted or moved after placement

Items are not flashed. (Only in emergent situations.) closed container is used to transport to sterile field

Labeling on sterile field performed

Surgical Hand Scrub

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

Scrubbed personnel do not contaminate themselves while gowning and gloving

Skin prep of patient

Hair is removed outside of OR using clippers

Skin prep is performed according to manufacturer's directions and a sceptic technique. Agent used: _________

Sufficient dry time is allowed prior to draping


Instruments are maintained by wiping excessive blood and debris with water

During procedure, cannulated instruments or those w/lumens are irrigated with water

Instrumentation soaked with water or pre-enzymatic


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

Traffic pattern avoids sterile field

Environmental Cleaning

Horizontal surfaces are free of dust and debris

After procedure, reusable items are cleaned between patients (straps, positioners, etc)

After procedure, visibly soiled areas of the floor (3-4 foot perimeter around bed) is mopped free of all blood and debris

Post Procedure

Instruments transported in covers container to soiled area

IC Director or Inspector
OR Director or Manager
Circulating Nurse
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.