Person(s) Doing Tracer: _____________________

Department Being Traced: _________________________

Date of Tracer: __________ Time of Tracer: __________

SAMC - Regulatory Readiness - Patient Tracer Tool for the Surgery/OR

Ques Question #

Compliant
Possible Responses
(Either Stated, Observed or Documented)

Non N/A Compliant

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22

Observation of surgical case; sterility maintained? Instruments protected? Appropriate instrument handling at end of case. Adequate and timely Hand scrub prior to case.

Check instrument wrap, locks on sterile trays, filters on Aesculab trays and indicators in trays Observe the process Observe the process

hand off

hand off Infection Control

Infection Control

Infection Control Infection Control Infection Control Infection Control Infection Control Infection Control Infection Control Infection Control Medication Safety Medication Safety

In the OR: scrubs on and caps covering all hair? Observe the process Warm up jackets available? Observation: Leaving the OR masks, shoe covers Observe the process removed and disposed of properly. Observation: Leaving the OR cover gowns securely Observe the process fastened. How are hand offs handled between OR and DS? Pre-op checklist, verbal report. How do you ensure that adequate pertinent Follow guidelines for handoff/hand over of patient information is shared with others providing services to from one area to another. Staff should be able to your patients ask questions. How do you update staff members when shifts Verbal report; written report; patient included?; change? PACU faxes report/calls floor; etc. Do you know the 3 occasions when soap and water Visibly soiled, after using restroom, after patient are needed for hand hygiene? contract. Hand hygiene, Use of PPE, Isolation precautions are How do you reduce the risk of hospital acquired followed. Proper techniques for dressing changes; infections? IV's, central lines, Foley Insertion and maintenance. Use of gels and antibiotics. No food or drink in patient care areas. Scrub sinks Observation: Bloodborne pathogen precautions free of used brushes/fingernail picks Disinfection of supplies and equipment in performed Proper PPE used. in accordance with SAMC practice. Is there documentation of terminal cleaning in the Validate documentation OR? Hand gel or handwashing used before and after Observe hand hygiene practices while doing tracer. touching patient or when leaving one patient room Compliance seen? and before entering another room. Have staff show you where to find the Infection Go to SAMC intranet homepage. Find link to Control Manual. Infection control manual. Staff training, housekeeping procedures, hand What infection prevention and control activities are hygiene. Cleaning, disinfection and sterilization of performed on unit? equipment, etc. Are needle boxes less than 75% full? Is clean linen covered? Is clean linen separated from dirty? Are refrigerators appropriately labeled? (medications only/tissue only) Do refrigerators have current temp logs? Refrigerator temperature monitored by facilities.

Page 1 of 6

Person(s) Doing Tracer: _____________________

Department Being Traced: _________________________

Date of Tracer: __________ Time of Tracer: __________

SAMC - Regulatory Readiness - Patient Tracer Tool for the Surgery/OR

Compliant
(Either Stated, Observed or Documented)

Non N/A Compliant

Medication Safety

23 24 25 26

What is done to ensure medication is given safely? What are the 2 patient identifiers used at SAMC? When do you check these identifiers? Are you labeling specimens with scrub and circulator verification? Why should this be done? What is special about blood transfusion and pt ID?

Patient ID

Patient ID

Patient ID

Patient ID

27

Patient ID

28

When are syringes, basins, medications, cups. Etc labeled?

Review medication/order/perform patient identification. Reinforces 5 rights of medication administration. Medications verified by 2 staff members one of which is an RN. Name and DOB. Patient/family member should be involved. Introducing self to patient, before specimen collection, procedures, blood draws, during surgical "time-out". Yes, So that the specimens are labeled correctly. Focus on one patient at a time. Two person bedside verification with a qualified transfusionist and qualified staff who can participate in the process. Anesthesia documents time of starting and completion of transfusion as well as vital signs. Syringes, basins, solutions should be labeled so there is no confusion. Medications should be labeled if they are not administered immediately after being drawn up.

Patient ID

29 30 31

Interview a patient or two. Ask them to describe the Patient should state 2 parts- Name and DOB (when patient identification process. receiving medications, blood draws, any procedure) If language or literacy issues apparent, where they Language line called and documented. Special addressed appropriately? brochures supplied if needed. Go to specialty area. Randomly check 5-10 supply Make sure staff know the appropriate disposal expiration dates. Check sterile water. Check fluids in process if items are outdated. Sterile water goes in warmers. red box etc. To prevent wrong site, wrong procedure, wrong person surgery. (Pre procedure checklist, site What is the Universal Protocol purpose? marking and time outs are required for all percutaneous procedures in any setting) All invasive and percutaneous procedures require What procedures does Universal Protocol apply? universal protocol. 1) Pre-op verification; 2) Surgical Site Marking; 3) What are the 3 components of the Universal Protocol? Time Our prior to procedure Yes. Check chart to see if Universal Protocol Did the patient have a procedure requiring Universal document is on chart and filled out completely and Protocol? If so, how was it documented? accurately. Document is evident. Name any 5 steps in a timeout. Are all cardboard boxes off the floor and no original shipping boxes found? Are ceiling tiles intact and without stains? 1) Correct patient, 2) correct side/site, 3) agreement of procedure, 4) correct patient position, and 5) availability of correct implants or special equipment Specificy exact location of any issues Specificy exact location of any issues
Page 2 of 6

Patient family involvement

supplies

Universal Protocol

32 33 34 35

Universal Protocol Universal Protocol Universal Protocol

Universal Protocol

36 37 38

Environment of care Environment of care

Person(s) Doing Tracer: _____________________

Department Being Traced: _________________________

Date of Tracer: __________ Time of Tracer: __________

SAMC - Regulatory Readiness - Patient Tracer Tool for the Surgery/OR

Ques Question #

Compliant
Possible Responses
(Either Stated, Observed or Documented)

Non N/A Compliant

39 40 41 42

Are floor coverings and moldings intact?

Specificy exact location of any issues

Are only Hospital approved soaps, hand scrubs Observe available for staff use? Are cleaning supplies safely secured with appropriate Observe labeling? Are areas under sinks free of contents. Observe

How much time did it take to complete this tracer? _________________________________

Page 3 of 6

Person(s) Doing Tracer: _____________________

Department Being Traced: _________________________

Date of Tracer: __________ Time of Tracer: __________

Comments

Page 4 of 6

Person(s) Doing Tracer: _____________________

Department Being Traced: _________________________

Date of Tracer: __________ Time of Tracer: __________

Comments

Page 5 of 6

Person(s) Doing Tracer: _____________________

Department Being Traced: _________________________

Date of Tracer: __________ Time of Tracer: __________

Comments

Page 6 of 6