UWNI Sterile Processing Observation - IP

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In the decontamination room, is ventilation negative in relationship to adjacent areas? Check alarms on door or perform a tissue test near the bottom of the door to confirm ventilation is flowing into the decontamination room.
Is staff using PPE when cleaning and decontaminating devices and/or equipment in accordance with department policy? For decontamination, full PPE should be worn - impervious gown, gloves, mask, and eye protection.
Select a chemical (disinfectant, enzymatic cleaner) in use and ask staff to locate the Safety Data Sheet.
Are enzymatic cleaners and detergents used and discarded according to manufacturer’s instructions and policies? Observe to verify staff is using appropriate concentration measurements per manufacturer's instruction; staff should speak to manufacturer's instruction for discarding [typically after each use].
Does the Tech use a thermometer to test the temperature of the detergent solution?
Is the Tech able to identify all instruments that come apart for cleaning?
Observe that all instruments and cannulas are brushed underwater. (Use a clean brush, remove visible soil, and repeat until brush comes out clean.)
Observe that all cannulas and areas that hold bioburden are flushed underwater.
If instruments require a soak time, is Tech performing the soak for the appropriate time? (i.e. Robotics soak for 30 minutes)
Does the Tech know what areas on the instruments to check for bone debris and bioburden?
Does the Tech use the ultrasonic when necessary? (i.e. robotics, suctions, lap instruments, kerrisons)
Observe that the Tech can distinguish hand wash ONLY items from instruments that go through the mechanical washer.
Is the Tech handwashing in a clean sink with new enzymatic detergent and new sponge or brush?
Are instruments organized in wash baskets? (Instruments should be placed so water and detergent can penetrate and drain through instruments, rinsing loose bioburden away for safety)
Observe the process for the care of cleaning brushes. (Disposable [single use] cleaning brushes are discarded after each use AND nondisposable brushes are cleaned and high-level disinfected or sterilized [per manufacturer’s instructions] after each use).
Describe the process for the use of biological indicators (BI). (BI used at the frequency recommended by the manufacturer for each sterilizer and with every load.)
For dynamic air removal-type sterilizers, how often is a Bowie-Dick test performed? (Each day the sterilizer is used to verify efficacy of air removal.)
How are you sure you are cleaning, decontaminating, or sterilizing something per the manufacturer's instructions for use (IFU)?
Where are departmental policies and procedures located?
How are the temperature and humidity levels monitored and recorded? Temperature and Humidity Ranges - Decontamination Area: 60-65 degrees Fahrenheit; 30-60% Humidity - Assembly Work Area: 68-73 degrees Fahrenheit; 30-60% Humidity
How would you address a temperature or humidity that is out of range?
When do you perform quality testing on your washers or sonics and where are results recorded?
In the event a deficiency is identified during quality testing of washers and sonics, how is the deficiency reported?
Who is responsibile for daily cleaning? Weekly cleaning?
What is the clearance level for storage shelves? 18" from ceiling level of sprinkler head and 8-10" from the floor and bottom shelf should be solid
What is the policy/process for utilizing loaner instruments and how do you know the manufacturer's IFUs?
Is the SPD Pass Through Window in the closed position when not in use?
Are peel pouches used per manufacturer’s instructions? Examine two double peel pouches for proper packaging process (no folding of inner pouch).
Staff can locate an eyewash station and it can be reached within 10 seconds/55 feet, unobstructed path.
Review documentation of eyewash checks on the tag at the station for the last month. Does documentation include weekly checks?

Sterile Supply Storage

Sterile Supply Storage Location Observed
Are sterile items in sterile storage rooms stored in a manner to prevent contamination? No metal on top of wrapped items Packaging is not crushed, bent, compressed or punctured Items are 8-10" from floor Items are 18" from ceiling or sprinkler heads Items are 2" from outside wall
How are the temperature and humidity levels monitored and recorded? - Sterile Storage: 75 degrees Fahrenheit or lower; Not to exceed 70% Humidity
Are peel pouches used per manufacturer’s instructions? Examine two double peel pouches for proper packaging process (no folding of inner pouch).