Download Periop Checklist UNC

OR OBSERVATION CHECKLIST
Date of observation: ______ Time: from ________ to ________ OR# ________ Observers: ____________________________________
Procedure(s): _______________________ Service: _____ Attending: _____________ Anesthesia Attending: ____________ # Persons in OR: ____
Specify parts of procedure observed: _______________________________________________________________________________________________
OR/PATIENT STANDARDS
OR Environment:
OR appears clean
OR facility in good repair
Sub-sterile area appears clean
Scrub sink area appears clean
Interim (between cases) cleaning
performed
Ventilation requirements:

Positive pressure

Doors closed
Temperature 68 degrees F

If not, changed for case
by anesthesia?
Perioperative Patient Care:
Pre-op shower documented
Patient drug allergies noted
Pre-op antibiotic given by anesthesia
personnel within 60 minutes prior to
incision
Intra-op abx if indicated given at
appropriate intervals
Injection ports swabbed prior to
access
Hair removal:

Method

Site(s)

Pt. Location where done
Pre-op skin prep:

Antiseptic used

Application technique
Compliant:
YES
Compliant:
NO
NA
DESCRIPTION/COMMENTS
Antibiotic Name:
Dose:
Times given:
(Indicate if drug different than pre-op abx)
Name antiseptic
Describe application method
PERSONNEL STANDARDS
Attire:
Properly tied surgical masks
Surgical caps/hood covering all hair
Dress code followed:

Jewelry

Fanny packs

Long sleeves

Turtlenecks

Shirts tucked
Only those in appropriate attire enter
the OR
Surgical Hand Scrub

Product used

Correct procedure for product

Nail cleaner used for first case
No artificial nails, natural nails correct
length
Sterile Field:
Sterile items left open no > than 30
minutes prior to patient entering room
Scrubbed persons maintain sterility of
sterile gown, gloves, supplies
Hands remain above waist
Sterile field constantly monitored
Items introduced into sterile field
opened, dispensed, transferred by
methods to maintain sterility/integrity
Items/devices dropped below level of
the OR table are considered
contaminated
All personnel moving in/around sterile
field do so in manner to maintain
sterility
Adjacent sterile fields not at disparate
heights
Separation of sterile team from nonsterile team maintained
Staff do not turn back to sterile field
Traffic in and out of room kept to
minimum
Compliant:
YES
Compliant:
NO
DESCRIPTION/COMMENTS
Name product:
ADDITIONAL STANDARDS
Anesthesiology:
Drainage bags kept off the floor
Aseptic practice used for IV tubing,
fluids, medications
Aseptic practice used for all invasive
procedures: (epidurals, blocks, IV
insertion)
Anesthesia cart appears clean
Cleans shared equipment (e.g,
stethoscope) between cases
OSHA/Bloodborne Pathogens
Appropriate eye protection used
Sharps containers not overfull
Shoe covers/boots if indicated
Surgeons/first assistants double
gloved (recommended)
Circulators wear latex/nitrile gloves
for handling contaminated items.
Performs hand hygiene after glove
removal
Sharps are passed in a basin or by
using neutral zone rather than by
hand
Sharps safety devices
General Infection Control:
Patients with communicable disease
handled appropriately
Sterile team removes gloves and
washes hands at end of case
Policies regarding flash sterilization
are followed
Personnel appear free from
communicable disease (no open skin
lesions on hands/face)
Observers comply with “Observers
Protocol” for Surgical Services
Clean, sterile, and soiled items are
kept separate
Patient transported via clean corridor
Compliant:
YES
Compliant:
NO
DESCRIPTION/COMMENTS
Devices used: