Information
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Document No.
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Audit Title
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
OR suite inspection
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Floors & walls clean
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Walls free of breaks and penetrations
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Ceiling free of visible dampness or damage
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No high dust present
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No dust on equipment or supplies, no damaged equipment or supplies
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Sterilized trays are free of dust, unopened, no tears
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Supplies > 18" from ceiling and 6" above floor on lined shelving
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OR suite properly stocked without clutter
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No expired supplies
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PPE including gloves available
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ONLY sharps in sharps box
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Sharps boxes <1/3 full
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Nothing on top of sharps boxes
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Appropriate use of red bags (no regular trash)
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Computer & keyboards dust free and clean
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No tape residue on equipment or on table
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Patient table clean, no soil found when broken down
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Stands, kick buckets clean
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Wheels, furniture, lights clean (no rusty wheels)
Anesthesia
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Cart clean, locked
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When unlocked by appropriate staff, no expired medications found
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No evidence of reuse of single dose vials
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Intubation equipment sealed in unopened peel packs, clean and sterilized
OR Desk
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Free of clutter
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No food or drink
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No laboratory samples at desk
Supply areas (sterile core)
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No high dust
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Blue bins without dust/debris
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Bottom of all shelves lined
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No expired equipment during spot check
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No expired supplies during spot check
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In sterile supply area: no unsterile supplies/packs
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Able to determine packs are sterile
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Floors clean
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No boxes on the floor
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Ceiling free of visible dampness/damage
Sub-sterile Rooms
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Flash log present and used on each load, patient sticker or ID present
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Autoclave clean
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Counter tops clean and no damage/chips
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Walls & floors clean
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No expired equipment or supplies
SPD
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Decontamination area clean
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Proper chemicals present for precleaning
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Washer in working order
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Ultrasonic unit: on 10 minutes prior to use, use of pH neutral solution, instruments are open, unit not overloaded, metals are same types, instruments are immediately removed when complete.
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Ultrasonic properly tested (see waves)
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Able to determine if instruments are rust vs stains (eraser test- rust will be removed w eraser)
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Steris strips dated w/in 90 days of expiration
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Chemicals are not expired, dates are circled
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Steris logs are up to date
Soiled Utility Rooms
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Cleaning products stored properly
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Mop water and buckets clean
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Cleaning tools clean
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Adequate supply of cleaning materials
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Soiled materials segregated
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Floors clean
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PPE available
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Red bags tied properly
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Trash bins clean
Hallways/Scrub areas
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All storage to one side of hall
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No cleaning products in the hall
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Scrub sinks, foot pads clean
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X-ray aprons clean, stored properly
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Radiology equipment clean and properly stickered (PM).
Staff Inspection
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Hair covered
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Scrub procedure monitored
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PPE worn as appropriate
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OR staff at bedside in proper sterile attire
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No fleece sweaters, warm up clothing
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No obvious signs of infection noted
OR Procedure
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Pre-op hair removal prior to OR entry
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Proper prep method noted
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Sterile procedure not violated (maintain proper distance from sterile areas, drop only sterile supplies onto field, scrub Tech does not drop their arms during procedure below waist. MD maintains sterile field.
Other
Action Plan
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Action plan due to Infection Control by:<br><br>Action plan as decided by Director or designee:<br><br><br><br>
Signatures
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OR Director or Designee
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Infection Control Director
