Mask covers nose and mouth and is tied securely YES NO Mask in place when entering operating/procedure room and sterile packs open YES NO and when in sterile core Sterile left open no more than 60 minutes prior to patient entering room YES NO and should be constantly monitored during that time period Scrubbed persons maintain sterility of sterile gown, gloves, supplies (e.g., YES NO while waiting for procedures to be done such as X-Rays?) Chemical indicators must be checked when instruments are opened, before Yes NO they are placed on the sterile field Items introduced into sterile field are opened, dispensed, and transferred by YES NO methods to maintain sterility/integrity Items/devices dropped below level of the operating/procedure room table are YES NO considered contaminated Is the drape between anesthesia and patient above the level of YES NO anesthesiologist’s nose and mouth? Do anesthesia personnel lean over drape during procedure? YES NO Surgical equipment (e.g. cables, tubing) should be secured to sterile field with YES NO non-perforating devices Nonsterile equipment (e.g., mayo stands, C arms) should be covered with sterile barrier materials; only sterile items should touch sterile surfaces; sterile YES NO barrier material should be applied to any equipment adjacent to the sterile field All personnel moving in/around sterile field do so in manner to maintain sterility, for example: Staff do not turn back to sterile field Scrubbed personnel pass front to front or back to back YES NO Hands remain above waist Separation of sterile team from non-sterile team maintained Unscrubbed personnel do not pass between two sterile fields VI. Anesthesiology Drainage bags (e.g., foley) kept off the floor YES NO Aseptic practice used for IV tubing, fluids, medications injection ports – YES NO swabbed prior to access Sterile equipment including IV solution/tubing is assembled immediately YES NO prior to use Aseptic practice used for all invasive procedures (e.g., epidurals, blocks, IV YES NO insertion) Was antibiotic infusion mentioned/checked prior to incision? YES NO Was antibiotic infusion repeated if surgery is longer than 4 hours? YES NO Note: type of ATB may require repeat dose Anesthesia cart appears clean; handsanitizer readily available YES NO Re-usable personal equipment (e.g., stethoscope) cleaned between cases YES NO
Mask covers nose and mouth and is tied securely YES NO Mask in place when entering operating/procedure room and sterile packs open and when in sterile core YES NO Sterile left open no more than 60 minutes prior to patient entering room and should be constantly monitored during that time period YES NO Scrubbed persons maintain sterility of sterile gown, gloves, supplies (e.g., while waiting for procedures to be done such as X-Rays?) YES NO Chemical indicators must be checked when instruments are opened, before they are placed on the sterile field Yes NO Items introduced into sterile field are opened, dispensed, and transferred by methods to maintain sterility/integrity YES NO Items/devices dropped below level of the operating/procedure room table are considered contaminated YES NO Is the drape between anesthesia and patient above the level of anesthesiologist’s nose and mouth? YES NO Do anesthesia personnel lean over drape during procedure? YES NO Surgical equipment (e.g. cables, tubing) should be secured to sterile field with non-perforating devices YES NO Nonsterile equipment (e.g., mayo stands, C arms) should be covered with sterile barrier materials; only sterile items should touch sterile surfaces; sterile barrier material should be applied to any equipment adjacent to the sterile field YES NO All personnel moving in/around sterile field do so in manner to maintain sterility, for example: Staff do not turn back to sterile field Scrubbed personnel pass front to front or back to back Hands remain above waist Separation of sterile team from non-sterile team maintained Unscrubbed personnel do not pass between two sterile fields YES NO VI. Anesthesiology Drainage bags (e.g., foley) kept off the floor YES NO Aseptic practice used for IV tubing, fluids, medications – injection ports swabbed prior to access YES NO Sterile equipment including IV solution/tubing is assembled immediately prior to use YES NO Aseptic practice used for all invasive procedures (e.g., epidurals, blocks, IV insertion) YES NO Was antibiotic infusion mentioned/checked prior to incision? YES NO Was antibiotic infusion repeated if surgery is longer than 4 hours? YES NO Note: type of ATB may require repeat dose Anesthesia cart appears clean; handsanitizer readily available YES NO Re-usable personal equipment (e.g., stethoscope) cleaned between cases YES NO
1.02_Operating_Procedure_Room_Observation_Tool_1.docx