Audit

General Infection Control Practices & Safety

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

Cleaning

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

Storage

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)

Anesthesia Cart

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

Waste Management

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

Soiled Utility Rooms

Cleaning products stored properly

Mop water and buckets clean

Cleaning tools clean

Soiled materials segregated

Floors clean

PPE available

Red bags tied properly

Trash bins clean

Hallways/Scrub areas

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).

Staff and Space / Work Flow

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 Knowledge

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.

Other Findings

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Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.