OR Intraoperative Inspection Record

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• OR #

• Procedure:

• Surgeon:

• Assistant:

• Anesthesiologist

• Circulating RN

• Scrub Tech(s):

• Relief staff:

• Other:

• Time out according to policy

  Yes

  No

  N/A

• Abx timing addressed by Surgeon

  Yes

  No

  N/A

Surgical Attire (every person)

• Top is secure or close to the body

  Yes

  No

  N/A

• All hair is covered

  Yes

  No

  N/A

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

  Yes

  No

  N/A

Sterile Technique

• Sterile field is prepared close to the time of surgery

  Yes

  No

  N/A

• Sterilized items at transported in covered or enclosed cases/carts

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Labeling on sterile field performed

  Yes

  No

  N/A

Surgical Hand Scrub

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

  Yes

  No

  N/A

• Scrubbed personnel do not contaminate themselves while gowning and gloving

  Yes

  No

  N/A

Skin prep of patient

• Hair is removed outside of OR using clippers

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Sufficient dry time is allowed prior to draping

  Yes

  No

  N/A

Intraoperative

• Instruments are maintained by wiping excessive blood and debris with water

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Instrumentation soaked with water or pre-enzymatic

  Yes

  No

  N/A

Traffic

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

  Yes

  No

  N/A

• Traffic pattern avoids sterile field

  Yes

  No

  N/A

Environmental Cleaning

• Horizontal surfaces are free of dust and debris

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

Post Procedure

• Instruments transported in covers container to soiled area

  Yes

  No

  N/A

• IC Director or Inspector

  Sign

• OR Director or Manager

  Sign

• Circulating Nurse

  Sign