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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: