Information
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Surgical Services Infection Prevention Audit
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Conducted on
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Prepared by
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Personnel Attending the Rounds:
General Infection Control Practices & Safety
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Staff can locate Infection Prevention Policies
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Staff can articulate and locate the Bloodborne Pathogen Exposure Policy
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Staff can locate the SDS
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Appropriate PPE available
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Staff is observed using PPE appropriately
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PPE is disposed at point of use
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Sinks properly located and functioning
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Hand washing stations/ scrub sinks are stocked with towels, soap, surgical hand scrub, nail cleaners and brushes
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Waterless surgical scrub available
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Hand Hygiene before and after patient care
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Hospital approved hand lotion is available
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No artificial nails/products worn by direct patient care staff
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No staff food, drinks, cosmetics, applying of contact lenses, use of personal lotions, or storing of personal items in patient care areas
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Hospital approved disinfectant is available
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Staff correctly observe isolation precautions posted for patients
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Single use items (scissors, tweezers) not re-used
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Enzymatic cleaner available in each OR
Cleaning
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Ceiling tiles are in place, dry and free from stains, cracks, and holes
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High level dusting has been done.
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Air supply grills are clean and free of dust.
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Return grills are clean, dust free and are not blocked by equipment.
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All surfaces free of dust and debris.
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All equipment are clean.
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Equipment does not have rust.
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Equipment with current inspection stickers
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Equipment cleaned according to manufacturer's recommendations
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All appliances for prep/storage of medications are visibly clean
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OR is cleaned between patients and at the end of the day per policy
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Patient table clean, no dirt, bodily fluids, rust... found when broken down
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Mattresses /cushions are clean with no holes / cracks / tears
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Anesthesia cart is clean.
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Sterilizers in the Core are clean
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EVS closet is clean, organized and secure
Storage
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Clean utility room is clean and organized
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Dirty utility room is labeled, clean and secured
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Clean equipment is stored separately from soiled equipment
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Storage units/shelves have solid bottoms
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Storage units /bins/shelving are clean and organized
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Storage of supplies is clean and organized
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Supplies > or = to 18" from ceiling and 10" above floor on lined shelving
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No items stored on the floor
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No expired supplies
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Items are stored in a manner that will not compromise sterility (compressed, crushed, susceptible to tears, away from sources of moisture)
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No torn or compromised supplies
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Sterilized trays are free of dust, unopened, no tears
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Inappropriate or unnecessary equipment and supplies are not present in the area
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All medications are secured with access only to authorized hospital personnel. narcotics are secured and stored separate from other medications
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All open vials of medications have an expiration date from the manufacturers with no obvious signs of contamination, and are dated when opened. Multi-dose vials expire within 28 days of opening (USP 797)
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Refrigerator thermometers reads 36-45 degrees Fahrenheit
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Refrigerator and freezer logs are read at least twice a day (twice if used to store vaccines) (CDC)
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Refrigerator and freezer temperature logs are dated and signed by the person performing the check and are readily available if requested (CDC)
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Staff able to articulate the action taken if temperature is out of range
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Corrective action is documented if temperature is out of range
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Linen carts/ room are clean and organized
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Linen carts in hallways or combined storage rooms are covered.
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Items are stored in appropriate or safe locations (nothing on top of trash containers, shred bins, blocking hallways, doors or exits)
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Supplies are not stored where food/ drinks are consumed. (or no food /drinks in supply room)
Anesthesia Cart
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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
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Free of clutter
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No food or drink nor personal belongings.<br>
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No laboratory samples at desk
Waste Management
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Biohazardous waste containers do not hold regular trash
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No biohazardous waste in the regular trash containers
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Waste holding areas and carts are clean
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Sharps containers are secured
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ONLY sharps in sharps box
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Nothing on top of sharps boxes
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Sharps boxes <2/3 full
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Dirty linen hamper is no more than 3/4 full
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Dirty linen is covered and transported in leak resistant container
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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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 unlabeled and unattended cleaning products in the hall
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Scrub sinks, foot pads clean and free of rust
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Lead aprons clean, stored properly. Staff able to articulate cleaning and disinfection after use.<br>
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Radiology equipment clean and properly stickered (PM).
Staff and Space / Work Flow
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Appropriate attire is worn<br>
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Doors are not propped open
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Hallways are clean and uncluttered.
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Egress corridors are free from obstruction
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Temperature in OR rooms is according to standards and documented.<br>
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Humidity in OR rooms is according to standards and documented.<br>
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Each OR room has appropriate number of air exchanges per standards. (at least 20 /hr)
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Anesthesia cart where meds are stored is clean and secured.
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Medication carts/meds are clean and secured.
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Laryngoscope blades are sealed in peel packs.<br>
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Compressed gas is secured (Ultane)
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Yankauer suction tip is not open or left from previous case.
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Soiled linen is collected and transported to designated dirty utility area in a covered leak proof container
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Sterilization records are filled out completely (Immediate Use Sterilization done in the OR)
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Sterilizers in the Core are not allowed free flow of steam to Core
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Fans are not present in the OP or in the Core.
Staff Knowledge
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Staff able to articulate the 5 moments of hand hygiene
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Staff able to articulate the care of instruments at point of care.
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Staff able to articulate how isolation patients are identified.
Other Findings
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