Title Page

  • Site conducted

  • Conducted on

  • Prepared by

  • Location

Surgery Observation Checklist

Surgical Attire

  • Staff is wearing hospital approved scrubs

  • Top is secured at waist, tucked in or close to body

  • All hair covered

  • No visible jewelry worn by scrubbed and non-scrubbed staff

  • Mask is secured with both ties in the presence of open sterile items and equipment

  • Cover gowns/jackets are worn and secured to prevent inadvertent contamination while walking past sterile field

  • Dedicated shoes or shoe covers are worn

Sterile Technique

  • Sterile field is maintained throughout the procedure with traffic patterns established with a minimum of one foot perimeter respected by the unsterile personnel

  • Sterile items are presented to scrubbed person or placed securely on field

  • Liquids are poured only once, without splashing, and the remainder discarded

  • Draping is accomplished in a sterile manner: (Performed by a minimum of two people; Hands are cuffed while presenting drapes to unsterile personnel; Anesthesia screen is not dropped prior to placement; Drapes are not lifted or moved after placement)

  • items are flash sterilized only in an emergency situation and a closed container is used for transport to the sterile field

Surgical Hand Scrub

  • Scrub is performed according to manufacturer's directions and aseptic technique

  • Scrubbed personnel do not contaminate themselves while gowning and gloving

Time Out

  • Observe universal protocol "Time Out"

  • Site marked prior to entry into OR suite (in pre-op holding area)

  • Circulator calls "Time Out"

  • Circulator checks patient's ID bracelet patient identification

  • Circulator states the correct site

  • Circulator reads aloud the surgical procedure to be done

  • Outpatient chart review - H&P reviewed and documented

Skin Prep

  • Hair is removed using clippers, if applicable

  • Skin prep is performed according to the manufacturer's directions and aseptic technique

  • Sufficient drying time is allowed prior to draping


  • Traffic in and out of the room is kept to essential personnel/tasks

  • The traffic pattern during the case avoids the sterile field whenever possible


  • OR doors are closed between cases

  • Sharps are removed and disposed of appropriately at the completion of each case

  • Sharps containers are accessible, secured to wall/counter and emptied when the "full" line is reached

  • Glass is disposed of in rigid containers

  • Biohazard waste is labeled and covered

  • No eating or drinking in patient care area

  • Isolation resources are available on isolation carts or other designated area

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