Surgery Observation Form

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• OR Personnel: Surgeon: Assistant: Anesthesia:

• Time out completed according to policy?

  Yes

  No

  N/A

• Abx timing addressed with Surgeon?

  Yes

  No

  N/A

Surgical Scrub

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

  Yes

  No

  N/A

• Scrubbing personnel do not contaminate themselves (or are not contaminated by others) while growing and gloving.

  Yes

  No

  N/A

Surgical Attire (every person)

• Top is secured or close to body.

  Yes

  No

  N/A

• All hair is covered. Cloth hair covers are covered by disposable hair cover.

  Yes

  No

  N/A

• Mask is worn securely in the presence of the sterile field. Masks are not reused.

  Yes

  No

  N/A

Surgical Prep of the Patient

• Hair is removed outside of the OR using clippers.

  Yes

  No

  N/A

• Skin prep is performed according to the manufacturer's directions and aseptic technique.

  Yes

  No

  N/A

• Prep agent:

• Sufficient dry time is allowed prior to draping without puddling of prep agent.

  Yes

  No

  N/A

Sterile Technique

• Draping is accomplished in a sterile manner with: Hands are cuffed while 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

• Sterile field is prepared close to the time of surgery.

  Yes

  No

  N/A

• Sterilized items are transported in covered or enclosed carts.

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Sterile persons do not turn their backs to the field or sterile supplies.

  Yes

  No

  N/A

• Sterile items are presented in a manner in which not to contaminate the field to scrubbed person or placed securely in field.

  Yes

  No

  N/A

• Liquids are poured once, without splashing, and remainder discarded.

  Yes

  No

  N/A

• Items are not flashed (IUS). If performed should only be due to emergency, closed container is used to transport yo sterile field and MD is made aware of BI result.

  Yes

  No

  N/A

• Used instruments are placed into pre-enzymatic cleaner, covered. Are covered for transport to CSR.

  Yes

  No

  N/A

Traffic

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

  Yes

  No

  N/A

• Traffic pattern avoids the sterile field.

  Yes

  No

  N/A

Environmental Cleaning

• Soiled instruments are removed from room in covered containers, marked as soiled.

  Yes

  No

  N/A

• Horizontal surfaces are free of dust and debris.

  Yes

  No

  N/A

• After procedure, reusable items are cleaned (such as straps).

  Yes

  No

  N/A

• After procedure, visibly soiled areas of the floor (3-4 foot perimeter around bed) is mopped.

  Yes

  No

  N/A

Other:

Action Plan

• Action plan due to Infection Control by: Action plan as decided by department Director and/or designee:

• Infection Control Practitioner

  Sign

• OR Director or Designee

  Sign