Title Page
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Site conducted
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Conducted on
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Prepared by
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Location
Attire
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Staff changed into scrubs at the hospital.
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Hair is covered
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No dangling earrings
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Mask is worn in the presence of open sterile items
Positioning
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Has an adequate number of personnel available for positioning activities.
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Ensures the patient is always attended by at least one team member when on the OR bed.
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Verifies placement, tightness and security of safety restraints after positioning or repositioning activities.
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Verifies the patient’s body is in physiologic alignment.
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Ensures OR/cart is in locked position.
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Uses OR beds, positioning equipment, devices and support surfaces correctly
Sterile Technique
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Places drapes with sterile technique.
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Keeps hands and arms above waist level and does not fold arms with hands on the axillary area.
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Avoids changing levels and is seated only when the entire operative is performed at the level.
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Remains close to the sterile field and touches on sterile areas or items.
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Corrects breaks in sterile technique.
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Specimen Collection
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Transfers/receives specimens as soon as possible.
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Verifies specimen with surgeon and or scrub tech, with runner, and/or in the lab.
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Labels specimens correctly.
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Confirms the use of formalin.
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Confirms laterality.
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Review specimens during sign out.
Sign In/Time Out/Sign Out
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Completes the sign in upon entering the room using the consent.
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Participates in time out.
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Suspension of all other activities during time out.
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Documents all time outs, including fire.
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Participates in sign out (conformation of specimens, post op procedure, confirmation of correct count.
Chloraprep
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Uses tuck towels.
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Sterile gloves for prepping.
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30 seconds at the incision site.
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2 min if in a moist area.
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Gentle friction.
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Clean to dirty principle.
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3 minute dry time.
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Correct number of prep ampules for surgical area.
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Not break ampule inside package.
Opening,Dispensing, Transferring Sterile Items
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Inspects item before opening.
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Doesn’t reach over sterile field.
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Presents heavy items directly to scrub or opens them on a separate surface.
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Secures the wrapper edges.
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Inspects the blue wrap for holes.
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Presents peel pouches without the inside of the package or allowing the contents to slow over the unsterile edges.
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Does not replace the cap on medication or solution containers.
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Counts
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Conducts the initial count before the patient enters the room.
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Counts items audibly, views items concurrently.
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If the count is interrupted, restarts the count.
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Records the count after opening an item to the sterile field and item is counted.
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It an item is passed or dropped, it is isolated from the field and included in the final count.
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Does not subtract or remove items from the count.
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Complete count when there is permanent relief.
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3 counts minimum.
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Uses pocketed sponge bad system.
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Counts instruments when appropriate.
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Not remove linen or trash until the patient is out of the room.
