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