• Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

  • OR #

  • Procedure:

  • Surgeon:

  • Assistant:

  • Anesthesiologist

  • Circulating RN

  • Scrub Tech(s):

  • Relief staff:

  • Other:

  • 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

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.