Title Page

  • Conducted on


  • Prepared by

  • Personnel



  • Containment cart/device clearly indicates contaminated items are present

  • Are contaminated items properly contained during transport?

  • Disposable sharps are NOT present

  • Has gross soil been removed from instrumentation

  • Instruments arrive moist in decontamination

  • PPE is available and used appropriately when removing contaminated items from cart/device

  • Time between arrival and decontamination is minimized

  • Transport carts/devices are decontaminated between each use


  • Appropriate PPE is available and donned for pre washing and manual wash

  • Sink, sonic and washer cleaning/disinfection chemicals are labeled, diluted properly for use, and within expiration

  • All lumens and cannulated instruments are pre-cleanedby brushing and flushing

  • Cleaning brushes are maintained in good condition and are cleaned and disinfected on a daily basis

  • Explain the process of soaking, rinsing instruments. Best practice is the process of rinsing occurring in a separate sink.

  • Water/detergent solutions are used in sink according to manufacturer's instruction for use (IFU)

  • Explain the process of changing the water at the instrument sink. The process Should always coincide with the manufacturer's instructions for use (IFU)


  • Explain the process of changing the water in the ultrasonic cleaner. The process should always coincide with the manufacturer's IFU.

  • Explain the process for instruments placed in the ultrasonic cleaner.

  • Explain the process for loading the mechanical instrument washers properly

  • Explain the process for delicate items that can't go into the instrument washers(Power equipment, micro and eye instruments)

  • Ultrasonic cleaners are tested at least weekly, passed and recorded. Ask to review the log

  • Mechanical instrument washers are tested at least weekly, passed and recorded. Ask to review the log


  • Instruments are inspected for cleanliness and properly functioning.

  • Instruments are evenly distributed in trays

  • No paper/plastic peel pouches inside instrument sets. Ask the staff to show you medical grade instrument bags

  • Hinged instruments are open/disassembled. Delicate instruments are protected with appropriate assessories


  • Are peel pouches used for lightweight instruments only(Maximum two (2) instruments)

  • Are the pouches use for the appropriate method of sterilization (Paper/plastic for steam/ETO, Tyvek/plastic for Sterrad) Along with the chemical indicators

  • Are the peel pouches sealed smoothly and air removed

  • If peel pouches are prepared as double; no folds present in the inner package

  • Are labels only on the plastic side


  • Are rigid containers maintained in good working order

  • Class 5 Chemical indicators are placed inside each set in the appropriate location according to the manufacturer's recommendations

  • Are rigid containers cleaned and decontaminated between each use

  • Are the rigid containers used within the manufacturer weight limits


  • Steam sterilizes are operating following manufacture instructions

  • Bowie-Dick test is performed daily before 1st load in Prevac sterilizer cycles

  • Biological indicators are used for monitoring sterilizers weekly but preferably daily. Ask the staff to explain the process

  • A biological indicator control is processed each day a test biological indicator is run

  • All sterilization monitoring devices are used correctly

  • Biological incubators are located and used according to the Manufacturer Instructions for use(IFU)


  • Biological indicators are used for monitoring sterilizers daily but preferably with each load

  • A biological control is processed each day a test BI is run

  • Appropriate biological indicator is used and positioned according to IFU

  • Biological indicators are located and used according to manufacturer Instructions for use (IFU)


  • Sterilization records are organized and easily retrieved

  • Sterilization logs contain the lot number, the date of the load, and the load contents(the sterilizer # and cycle sequence#)

  • What is the process for handling a positive biological indicator and recall is in place


  • Peel pouches stand on the edge in relation to the sterilizer cart

  • Mesh bottom pans/rigid containers are flat on the sterilizer cart shelf

  • If shelf liners are used; you may use them in multiple cycles but the staff must check the integrity of the liner prior to each load


  • Cycle printout checked before removing items

  • Items allowed to cool before handling

  • Distance between sterilized and clean items maintained


  • Storage area is clean and organized with no outside shipping containers

  • Sterile items are stored in a manner that will not compromise sterility

  • Sterile supplies are stored in closed cabinets or open shelving with solid bottom shelves or bottom shelves with liners

  • Storage shelving/carts are: 18" from the ceiling, 8-10" above the floor, and at least 2 " from the outside walls

  • Sterile supplies are rotated on the "first in, first out" concept


  • Department size is sufficient for the volume of work activities and to promote good work flow

  • Workflow in the department promotes a clear separation of dirty/clean/sterile processes

  • Doors and pass-through windows are kept closed when not in use

  • Temperature and humidity is monitored and documented. Ask the staff to explain the process and retrieve the log

  • Ventilation and airflow are appropriate in the decontamination and clean processing area

  • No fans present in the department

  • Overhead lighting is sufficient for inspection of surgical instruments during processing

  • Magnification available for detail inspection and used

  • Work area surfaces are cleaned daily or when soiled. Ask the staff to explain the cleaning process

  • All area floors are horizontal surfaces are cleaned on a daily basis and separating each side (decontamination/prep)

  • No inappropriate or unnecessary equipment and supplies present in decontamination

  • Traffic is restricted to authorized, appropriately attired personnel

  • Hand Washing sink in decontamination and prep areas and are only used for that purpose

  • Eyewash/shower present in decontamination and prep areas. Tested routinely and recorded.

  • Floors, walls, ceilings, and work surfaces are constructed of cleanable materials and are maintained in good condition


  • Pre-cleaning same as SPD routine process and separate from direct patient care area

  • Closed container or wrapping validated for IUSS

  • Cycle settings in correspondence to container manufacturer's IFU

  • What measures are taken to prevent contamination during transfer to sterile field. Ask the staff to explain the process

  • IUSS instruments are used immediately and not stored for any amount of time


  • All robotic instruments must coincide with the manufacturer's instructions for use. <br>The manufacturer recommend 15 minutes in the ultrasonic cleaner to flush the ports on the instruments. Ask to staff to articulate the process along with the IP.


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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.