ANESTHESIA INFECTION PREVENTION CHECKLIST
OR :__________________SUITE___________OBSERVER:___________________________
NAME:________________________________DATE:________________TIME:___________
MET
NOT
MET
MEASURE
Hands are washed prior to entering the OR
Hand hygiene performed:
1. prior to accessing/preparing clean supplies/medications
2. prior to gloving and when removing gloves
3. between dirty and clean steps of a procedure
Full barrier protection is worn for central line insertions and Central Line bundle is
followed and documented
Gloves are worn when inserting IVs
LMA/laryngoscopes are handled with gloves (hands sanitized first)
Gloves are removed after inserting or removing LMA/laryngoscope
Cover jackets are buttoned to the top and are removed at end of case when there is
patient contact or contact with body substances
Hair and head jewelry are totally covered by cap; no rings present, mask tied
Medications are drawn up and labeled at time of procedure
Used medication vials are stored on top of medication cart during procedure and
discarded prior to next case
Medication labels are stored in a clean location
Unused medications (drawn up syringes) are not transferred for use on next case
IV ports and medication stoppers are disinfected prior to entering
IV tubing does not hang below level of knees
CHG/alcohol prep used for skin prior to IV insertion
Single use items (medications/supplies) are discarded between patients
Topical ointments/tape are dispensed in a clean manner to avoid contamination
Sprays are handled in a clean manner to avoid contamination
Set up changed between patients (new towel)
Items dropped on floor are discarded
Medication/anesthesia cart surfaces and drawer handles are disinfected between
patients
Keyboard and mouse are disinfected between patients
Medications for next case are drawn up over a clean towel after hand hygiene
performed, placed in ziplock bag and stored in anesthesia cart drawer.