High-Level Disinfection (HLD)
Temperature, Humidity & Pressure
Device & Equipment Safety (Including Anesthesia Machines)
Time Out / Surgical Safety
Consent & History and Physical (H&P)
100

This must always happen before any item is high-level disinfected.

What is cleaning and rinsing per the manufacturer’s instructions for use (IFU)?

100

The acceptable temperature range in the OR is between these two numbers.

What is 68–75°F (20–24°C)?

100

This department is responsible for preventive maintenance and inspection of OR equipment.

What is Biomedical or Clinical Engineering?

100

This is the purpose of performing a surgical time out.

What is to verify the correct patient, procedure, and site before incision?

100

This person is responsible for obtaining informed consent.

Who is the licensed independent practitioner performing the procedure?

200

Before each HLD cycle, staff must verify that the disinfectant is still effective by doing this.

What is testing the solution with a chemical indicator strip and documenting the result?

200

The humidity in the operating room must stay within this range.

What is 20–60% relative humidity?

200

Before using an anesthesia machine or monitor, staff must always check for this.

What is a current inspection sticker, successful self-test, cleanliness, and functionality?

200

These team members must all participate in the surgical time out.

What is the entire surgical team — surgeon, anesthesia, and nursing?

200

Consent must always be completed before this point.

What is before sedation, anesthesia, or any invasive procedure begins?

300

The minimum amount of time an item must soak in high-level disinfectant is determined by this.

What is the manufacturer’s recommended contact time?

300

The OR must maintain this type of pressure compared to adjacent areas.

What is positive pressure?

300

When an alarm sounds on OR equipment, this should always be your first action.

What is assess the patient first, then troubleshoot the device?

300

The time out is performed at this point in the procedure.

What is immediately before the incision or start of the procedure?

300

A History & Physical is valid for this long before a procedure.

What is 30 days, with an update within 24 hours of admission or prior to surgery?

400

This occurs when the disinfectant test fails or when the solution expires per the manufacturer.

What is discarding and replacing the solution?

400

Temperature, humidity, and pressure should be monitored at least this often.

What is continuously (if electronically monitored) or at least daily?

400

If you find a frayed cord or gas leak on any OR equipment, you must do this immediately.

What is remove the device from service, tag it, and report it to Biomed?

400

Two of these identifiers must be used to confirm patient identity.

What are two patient identifiers such as name, date of birth, or MRN?

400

If the H&P is still current, this documentation must still be completed within 24 hours.

What is a written attestation stating the patient was examined and no changes occurred?

500

The HLD log must include this information about every disinfected item.

What are the date, item, test result, expiration date, staff initials/signature, and contact time?

500

If the environment goes out of range, staff must do these two things.

What is notify Facilities and document the variance with corrective actions?

500

This is how often life-support and anesthesia equipment must be inspected.

What is at least annually or per manufacturer/hospital policy?

500

If a discrepancy is found during the time out, this must happen.

What is the procedure stops until the issue is resolved and verified?

500

These elements make up a complete and compliant H&P.

What are medical/surgical history, allergies, medications, review of systems, physical exam, and plan?