Policy & Procedure Document

PART VII — FACILITY SAFETY, SECURITY, AND STAFF SAFETY (FMS)
SEC 13 — Independent OT Policies (13.1 to 13.8)

Operating Theatre Policy

POLICY 13.1 — OT Safety Rounds & Hazard Reporting

Department Operating Theatre (OT)
General Hospital
Version & Dates Version: 1.0
Effective: //20__
Review: //20__
Owner OT Nurse Manager + OT QPS Lead + FMS/Safety Officer
Policy Code & Title OT-FMS-13.1
OT Safety Rounds, Hazard Identification & Reporting (OT Scope)
Related Policies: SEC 3 (QPS / incident reporting), SEC 9 (IPC), SEC 12.5 (Remove from Service), SEC 13.2–13.7 (specific hazards)

1.0 PURPOSE

  • 1.1 To establish a structured OT Safety Rounds process that proactively identifies hazards, reduces harm, and ensures hazards are corrected, documented, escalated, and learned from.
  • 1.2 To ensure staff consistently report hazards and near misses (not only harm events), creating a reliable safety culture and evidence for accreditation.

2.0 SCOPE

  • 2.1 Applies to OT suite (restricted/semi-restricted/unrestricted OT areas), all OR rooms, scrub areas, sterile core interfaces, storage rooms, and OT corridors.
  • 2.2 Covers: planned safety rounds, ad hoc hazard reporting, immediate risk controls, escalation pathways, and closing the loop.

3.0 DEFINITIONS

  • 3.1 Hazard: Any condition with potential to cause harm (e.g., blocked exits, wet floors, missing fire extinguisher, gas leak alarm, malfunctioning equipment, radiation PPE missing).
  • 3.2 Near Miss: Event that could have caused harm but did not (e.g., loose oxygen hose discovered before case; uncovered sharps found before cleaning).
  • 3.3 Safety Round: A structured walk-through using a checklist and documented actions.

4.0 POLICY STATEMENT

  • 4.1 OT shall conduct scheduled Safety Rounds and maintain a simple, fast hazard reporting process available to all staff.
  • 4.2 Hazards are managed by priority: immediate risk control first, then full corrective action.
  • 4.3 Repeated hazards are treated as system defects and reviewed in OT QPS with corrective action plans and accountability.

5.0 ROLES AND RESPONSIBILITIES

  • 5.1 OT Nurse Manager: ensures program exists, audits occur, actions close.
  • 5.2 OT Charge Nurse: executes shift-level rounds, initiates immediate fixes, escalates unresolved hazards.
  • 5.3 FMS/Safety Officer: supports environmental hazards, maintenance tickets, fire/electrical compliance.
  • 5.4 Biomedical/Engineering: supports equipment hazards and tag-out (Policy 12.5).
  • 5.5 All staff: report hazards immediately and participate in rapid correction.

6.0 PROCEDURE

6.1 Safety Round Frequency (minimum):

  • 6.1.1 Daily quick check (charge nurse): critical life-safety items (exits, extinguishers visible, gas alarms normal, sharps bins not overfilled, spill kits).
  • 6.1.2 Weekly structured rounds (OT + FMS + IPC as needed): complete checklist.
  • 6.1.3 Monthly multidisciplinary rounds: OT leadership + FMS + Biomed + IPC + QPS review of trends.

6.2 What is checked (minimum domains):

  • 6.2.1 Fire readiness (extinguishers access, evacuation routes, oxygen shutoff awareness).
  • 6.2.2 Medical gas safety (pipeline outlets intact, cylinders secured, alarms).
  • 6.2.3 Electrical safety (cord integrity, approved power strips use, no daisy-chaining).
  • 6.2.4 Radiation readiness (lead PPE available, badges use).
  • 6.2.5 Waste segregation and sharps safety.
  • 6.2.6 Security/privacy (restricted access control, visitor compliance).

6.3 Hazard reporting workflow (OT fast pathway):

  • 6.3.1 Identify → announce → control risk immediately → report → escalate if unresolved.
  • 6.3.2 Examples of “control now”: block off wet floor; remove exposed sharps; tag equipment “remove from service.”
  • 6.3.3 Submit hazard report (paper/electronic) same shift; repeated hazards trigger QPS review.

6.4 Closing the loop:

  • 6.4.1 Every hazard must have: owner, corrective action, due date, verification, closure signature.
  • 6.4.2 Feedback is shared in OT huddle/noticeboard monthly.

7.0 DOCUMENTATION / RECORDS

  • 7.1 OT Safety Round checklist + action tracker.
  • 7.2 Hazard/near-miss reports.
  • 7.3 Maintenance/biomed tickets and closure confirmation.

8.0 AUDIT / KPIs

  • 8.1 % planned safety rounds completed on time.
  • 8.2 % hazards closed within due date.
  • 8.3 Repeat hazard rate (same defect recurring within 90 days).
  • 8.4 Safety event trend (sharps injury, electrical issues, gas alarms).
Operating Theatre Policy

POLICY 13.2 — Fire Safety in OT: Prevention & Response

Policy Code
Owner OT Director/Chair + OT Nurse Manager + FMS/Safety Officer
Related Policy 12.3 (ESU safety), Policy 11.8 (smoke), hospital fire plan

1.0 PURPOSE

  • 1.1 To prevent and respond to operating room fires by controlling the fire triangle (ignition source, oxidizer, fuel) and maintaining a disciplined emergency response.
  • 1.2 The Joint Commission Sentinel Event Alert 68 highlights that surgical fires continue to occur, and most are associated with electrosurgical devices during head/neck procedures, reinforcing the need for systematic prevention. (jointcommission.org)

2.0 SCOPE

  • 2.1 Applies to all OT areas, all OR cases, and all staff present.
  • 2.2 Includes prevention measures, high-risk case controls, drills, and response actions.

3.0 DEFINITIONS

  • 3.1 Fire triangle: oxidizer + ignition source + fuel. (jointcommission.org)
  • 3.2 High-risk fire case: head/neck surgery, open oxygen delivery, alcohol prep, laser/ESU.

4.0 POLICY STATEMENT

  • 4.1 OT shall perform fire risk controls whenever ignition sources are used, especially in head/neck cases and oxygen-enriched environments. (jointcommission.org)
  • 4.2 Alcohol-based skin prep must be allowed to dry fully; pooling under drapes is prohibited (fuel control).
  • 4.3 Active electrodes are holstered when not in use; ignition sources are kept away from fuels.
  • 4.4 OT shall train and drill fire response and maintain extinguishing readiness.

5.0 RESPONSIBILITIES

  • 5.1 Surgeon: controls ignition source use; participates in fire risk plan; stops energy if fire occurs.
  • 5.2 Anesthesia: manages oxidizer (oxygen/nitrous) per anesthesia/fire interface; supports airway fire response.
  • 5.3 Circulating nurse: ensures prep drying/avoid pooling; confirms extinguisher access; leads RACE activation.
  • 5.4 Charge nurse: ensures drills, signage, and fire equipment readiness; escalates hazards to FMS.

6.0 PROCEDURE

6.1 Prevention standard (every case with ESU/laser):

  • 6.1.1 Confirm prep agent and drying.
  • 6.1.2 Confirm drape placement prevents fuel accumulation and allows safe airflow.
  • 6.1.3 Confirm active electrode holster and safe placement when idle.
  • 6.1.4 Confirm communication plan for oxidizer control in high-risk cases.

6.2 High-risk head/neck + oxygen case controls:

  • 6.2.1 Conduct a formal fire risk briefing at Time-Out. (jointcommission.org)
  • 6.2.2 Use lowest feasible oxygen delivery consistent with clinical needs (anesthesia-led).
  • 6.2.3 Avoid open oxygen flow under drapes when possible.
  • 6.2.4 Ensure wet sponges available around field if required by local rule.

6.3 Response (fire in OR):

  • 6.3.1 Announce “FIRE.” Stop ignition source; stop oxidizer as appropriate (anesthesia).
  • 6.3.2 Remove burning materials if safe; extinguish using appropriate extinguisher technique; activate RACE/PASS per hospital policy.
  • 6.3.3 Evacuate if uncontrolled; close doors; follow facility fire plan.
  • 6.3.4 Document event; sequester involved equipment for investigation.

7.0 DOCUMENTATION

  • 7.1 Fire risk assessment in high-risk cases.
  • 7.2 Incident report for any fire, flash, near miss, or prep pooling event.

8.0 AUDIT / KPIs

  • 8.1 Fire drill completion rate.
  • 8.2 High-risk case fire risk briefing compliance.
  • 8.3 Fire/near-miss incidents per year.

9.0 REFERENCES

  • 9.1 Joint Commission Sentinel Event Alert 68 (updated surgical fire prevention). (jointcommission.org)
Operating Theatre Policy

POLICY 13.3 — Medical Gas Safety

Policy Code OT-FMS-13.3
Owner OT Nurse Manager + FMS/Engineering + Anesthesia liaison
Related Facility medical gas program (NFPA 99 governance), emergency codes
(Pipeline Awareness, Cylinder Handling — OT Scope)

POLICY CONTENT

1.0 PURPOSE

1.1 To prevent harm from medical gas system failures, cross-connections, cylinder mishandling, and oxygen-related hazards in OT by ensuring safe use of pipeline outlets, alarms, and cylinders.

1.2 NFPA 99 is the principal US consensus code covering health care facility systems including medical gas systems (used widely as a reference framework). (nfpa.org)

2.0 SCOPE

  • 2.1 Applies to OT staff actions involving: pipeline outlets (O₂/air/vacuum), zone valve awareness, cylinder storage and transport, and immediate response to leaks/alarms.
  • 2.2 Does not replace engineering verification/testing procedures; OT focuses on safe operations and escalation.

3.0 POLICY STATEMENT

  • 3.1 Cylinders must be secured (upright in holders/carts) and never left free-standing.
  • 3.2 Regulators, connectors, and hoses must be compatible and intact; improvised adapters are prohibited.
  • 3.3 Pipeline alarm events require immediate escalation to FMS/engineering and OT leadership; clinical risk is managed by the case team while the system issue is addressed.
  • 3.4 Oxygen is a powerful oxidizer—OT must treat oxygen-enriched environments as increased fire risk (interface with Fire Safety policy). (jointcommission.org)

4.0 PROCEDURE

4.1 Pipeline awareness (OT checks):

  • 4.1.1 Before cases: confirm outlet integrity (no cracks, loose fittings), correct labeling, and that hoses connect properly.
  • 4.1.2 Do not use damaged outlets; escalate to engineering and use alternative outlet/location if approved.

4.2 Cylinder handling:

  • 4.2.1 Use approved cylinder carts with chains/straps; caps used when required.
  • 4.2.2 Transport with valve closed when not in use; avoid heat sources and impact.
  • 4.2.3 Store cylinders in designated areas; segregate full/empty and label clearly (facility standard).

4.3 Leak/alarm response:

  • 4.3.1 If a leak is suspected: stop use if safe, remove ignition sources, ventilate per policy, and call engineering immediately.
  • 4.3.2 If pipeline alarm: charge nurse notifies engineering + OT leadership; document time and affected rooms; consider case flow controls until resolved.

5.0 DOCUMENTATION / AUDIT | 6.0 REFERENCES

5.0 DOCUMENTATION / AUDIT

  • 5.1 Gas alarm log (OT incident log) + engineering ticket.
  • 5.2 Monthly safety rounds include cylinder storage compliance.

6.0 REFERENCES

  • 6.1 NFPA 99 overview page (medical gas safety framework). (nfpa.org)
Operating Theatre Policy

POLICY 13.4 — Electrical Safety & Equipment Plug Rules

Policy Code OT-FMS-13.4
Owner OT Nurse Manager + Biomedical + FMS/Safety
Related Policy 12.5 remove-from-service, Policy 12.6 PM interface

1.0 PURPOSE | 2.0 POLICY STATEMENT

1.0 PURPOSE

1.1 To reduce electrical hazards (shock, fire, equipment failure, trip hazards) in OT by standardizing safe plug use, power strip rules, and pre-use inspection.

2.0 POLICY STATEMENT

  • 2.1 Electrical equipment must be inspected before use; if damaged, it must not be used until repaired (Joint Commission electrical safe use checklist). (jointcommission.org)
  • 2.2 Extension cords are not used as permanent wiring; “daisy chaining” power strips is prohibited.
  • 2.3 Power strips (relocatable power taps) are used only in permitted ways and must meet applicable UL standards; Joint Commission guidance specifies UL 1363 requirements for certain power strip use. (jointcommission.org)
  • 2.4 Life-support/critical patient-care devices are plugged directly into wall outlets (or into approved medical-grade solutions per facility engineering design) unless a manufacturer-tested assembly explicitly permits otherwise.
  • 2.5 Cables must not create trip hazards and must not run under rugs/drapes or through wet areas.

3.0 PROCEDURE

3.1 Pre-use inspection: check plug, cord insulation, strain relief, and casing; if any damage, remove from service and tag (Policy 12.5). (jointcommission.org)

3.2 Plug discipline:

  • 3.2.1 Use hospital-grade outlets where applicable.
  • 3.2.2 Do not overload sockets; do not use multi-adapters unless approved.
  • 3.2.3 Keep plugs dry; route cables away from fluids.

3.3 Power strip rules (OT):

  • 3.3.1 Only use facility-approved power strips in approved locations and applications; do not use in patient care vicinity unless allowed by facility rules based on NFPA/CMS requirements. (jointcommission.org)
  • 3.3.2 Do not mount strips in ways that trap heat or impede cleaning.
  • 3.3.3 No daisy chaining.

3.4 Wet-procedure electrical awareness:

  • 3.4.1 OT follows facility “wet location” rules (line isolation monitor awareness if installed); alarms are escalated immediately to engineering.

4.0 DOCUMENTATION / AUDIT | 5.0 REFERENCES

4.0 DOCUMENTATION / AUDIT

  • 4.1 Electrical hazard reports and remove-from-service tags.
  • 4.2 Monthly audit of power strip compliance.

5.0 REFERENCES

  • 5.1 Joint Commission FAQ: Relocatable Power Taps / UL standards. (jointcommission.org)
  • 5.2 CMS guidance allowing power strips with compliance to NFPA 99 requirements in patient care areas under conditions. (CMS)
  • 5.3 Joint Commission electrical equipment safe use checklist. (jointcommission.org)
Operating Theatre Policy

POLICY 13.5 — Radiation Safety in OT (C-Arm Workflows, PPE, Badges)

Policy Code OT-FMS-13.5
Owner OT Nurse Manager + RSO + Orthopedic/Trauma Lead
Related Facility radiation protection program; Imaging department rules
(OT Scope)

1.0 PURPOSE | 2.0 POLICY STATEMENT

1.0 PURPOSE

  • 1.1 To protect patients and staff from unnecessary radiation exposure during intraoperative fluoroscopy by enforcing ALARA principles (time, distance, shielding), PPE use, dosimetry badges, and safe workflow behaviors.
  • 1.2 IAEA guidance recommends lead aprons and shielding measures for staff working in fluoroscopy environments. (iaea.org)

2.0 POLICY STATEMENT

  • 2.1 OT shall apply ALARA: minimize fluoroscopy time, maximize distance, and use shielding. (iaea.org)
  • 2.2 Required PPE for staff in the fluoroscopy room includes lead apron and thyroid shield; lead eyewear is recommended when appropriate shielding is not consistently effective. (iaea.org)
  • 2.3 Staff working in fluoroscopy areas must wear assigned radiation badges as per facility program.
  • 2.4 OT shall implement a standardized “C-arm workflow” to reduce exposure, including positioning strategies and shielding use. (www-pub.iaea.org)

3.0 PROCEDURE

3.1 Pre-case planning: confirm C-arm need, PPE availability (aprons, thyroid shields, lead glasses if used), shields (ceiling-suspended/rolling shields), and badges.

3.2 Room positioning rules:

  • 3.2.1 Prefer X-ray tube under the table when feasible; use under-table drapes when available; maximize distance from source. (PMC)
  • 3.2.2 Only essential staff remain close during imaging; others step back behind shielding.
  • 3.2.3 Collimation and pulsed/low-dose settings used per imaging team practice (radiographer/physician lead).

3.3 Badge rules:

  • 3.3.1 Wear badge correctly (per RSO policy: usually at collar outside apron; second badge under apron if facility uses dual-badge approach).
  • 3.3.2 Badges are not shared; lost badges reported immediately.

3.4 Pregnancy considerations:

  • 3.4.1 Staff pregnancy declarations handled confidentially per RSO program; dose monitoring adjustments follow facility rules.
  • 3.4.2 Patient pregnancy screening follows hospital policy for imaging exposure.

3.5 Post-case: check PPE for damage, return shields, document fluoroscopy use where required.

4.0 AUDIT / KPIs | 5.0 REFERENCES

4.0 AUDIT / KPIs

  • 4.1 PPE compliance observation audits.
  • 4.2 Badge compliance rate.
  • 4.3 Dose report trends (RSO-led) and corrective actions.

5.0 REFERENCES

  • 5.1 IAEA RPOP: Radiation protection of medical staff in interventional fluoroscopy. (iaea.org)
  • 5.2 IAEA publication: Radiation Protection in Medicine (C-arm OR considerations). (www-pub.iaea.org)
  • 5.3 Occupational radiation protection article: apron + thyroid shield + shielding recommendations. (PMC)
  • 5.4 SFDA radiological health requirements (training and radiation protection program expectations).
Operating Theatre Policy

POLICY 13.6 — Waste Segregation (Sharps, Clinical, Cytotoxic, General)

Policy Code OT-FMS-13.6
Owner OT Nurse Manager + IPC + Waste Management Officer
Related SEC 9 (IPC), Policy 13.7 (Sharps), facility waste SOP

1.0 PURPOSE | 2.0 POLICY STATEMENT

1.0 PURPOSE

1.1 To ensure safe segregation, containment, and removal of healthcare waste generated in OT to prevent infection transmission, chemical exposure, and environmental harm. WHO describes healthcare waste categories and risks and emphasizes safe management.

2.0 POLICY STATEMENT

2.1 OT shall segregate waste at point of generation into:

  • a) general/non-hazardous waste,
  • b) infectious/clinical waste,
  • c) sharps waste (puncture-resistant container),
  • d) pharmaceutical waste (if applicable),
  • e) cytotoxic waste (if applicable),
  • f) pathological waste (as defined).
  • 2.2 Sharps are disposed into approved sharps containers immediately at point of use.
  • 2.3 Waste containers must be clearly labeled, not overfilled, and removed via defined routes.

3.0 PROCEDURE

3.1 Place correct bins at point of care (OR, anesthesia work area, scrub area). WHO waste guidance supports point-of-care segregation systems and appropriate container placement. (unemg.org)

3.2 Do not recap needles; do not hand-carry loose sharps.

3.3 Sharps container rules:

  • 3.3.1 Not overfilled; close and replace at fill line.
  • 3.3.2 Mounted securely; not placed on floor where tipping can occur.

3.4 Cytotoxic/chemotherapy waste (if generated): follow facility-defined cytotoxic stream and labeling.

3.5 Waste removal: sealed bags/closed containers; no leakage; follow dirty route.

4.0 AUDIT / KPIs | 5.0 REFERENCES

4.0 AUDIT / KPIs

  • 4.1 Segregation compliance audits.
  • 4.2 Overfilled sharps container events (trend).
  • 4.3 Waste-related exposure incidents (trend).

5.0 REFERENCES

  • 5.1 WHO healthcare waste fact sheet.
  • 5.2 WHO handbook: Safe management of wastes from health-care activities.
  • 5.3 National technical guidance example for healthcare waste management (segregation/containment principles). (istitlaa.ncc.gov.sa)
Operating Theatre Policy

POLICY 13.7 — Sharps Injury Prevention & Exposure Response (OT Workflow)

Policy Code OT-FMS-13.7
Owner OT Nurse Manager + IPC + Employee Health Lead
Related Policy 13.6 waste, SEC 11.3 counts (sharps control), SEC 3 incident reporting

1.0 PURPOSE | 2.0 POLICY STATEMENT

1.0 PURPOSE

  • 1.1 To prevent sharps injuries in OT and ensure immediate, standardized response to blood/body fluid exposure, including timely reporting, risk assessment, testing, and post-exposure prophylaxis (PEP) when indicated.
  • 1.2 CDC provides dedicated sharps safety program resources and a sharps safety workbook to prevent needlesticks.

2.0 POLICY STATEMENT

  • 2.1 Sharps injuries are preventable and are treated as serious safety events; OT maintains “no normalization” of sharps injuries.
  • 2.2 Standard prevention includes safe passing, neutral zone where adopted, immediate disposal, and sharps containers at point of use.
  • 2.3 Any exposure requires immediate first aid and urgent reporting; PEP decisions are time-sensitive and must follow the occupational health pathway and current guidelines.

3.0 PROCEDURE

3.1 Prevention (Standard Work)

  • 3.1.1 Use a sharps counter and controlled passing technique; announce sharps during handoffs.
  • 3.1.2 Do not recap needles (unless a device/technique requires and is approved).
  • 3.1.3 Dispose immediately into sharps container; do not leave sharps on drapes or instrument trays unattended.
  • 3.1.4 Replace sharps containers before overfill; overfill is prohibited.

3.2 Immediate Response (First Aid)

  • 3.2.1 Percutaneous injury: wash with soap/water; do not squeeze aggressively.
  • 3.2.2 Mucous membrane exposure: irrigate with water/saline promptly.
  • 3.2.3 Report immediately to charge nurse and occupational health/ED pathway.

3.3 Reporting and Evaluation

  • 3.3.1 Document: time, device type, depth, visible blood, source patient details if known, PPE worn.
  • 3.3.2 Source patient testing and exposed worker baseline testing follow facility protocol and current guidance (IPC/occupational health leads).

3.4 Post-Exposure Prophylaxis (PEP)

  • 3.4.1 HIV PEP: follow current U.S. Public Health Service recommendations (updated guidance exists and targets occupational health providers); start as soon as possible when indicated. (PMC)
  • 3.4.2 Hepatitis B: follow vaccination/immunity status and exposure risk; CDC guidance covers postexposure management for HCP.
  • 3.4.3 Hepatitis C: follow facility testing and follow-up pathway; CDC resources address exposure management in HCP.

3.5 Follow-Up and Work Restrictions

3.5.1 Follow occupational health schedule for follow-up tests and counseling; CDC HCP infection control guideline includes postexposure management considerations.

4.0 AUDIT / KPIs | 5.0 REFERENCES

4.0 AUDIT / KPIs

  • 4.1 Sharps injury rate per 1,000 cases.
  • 4.2 % injuries reported within 1 hour (or facility-defined).
  • 4.3 Safety device adoption rate where available.
  • 4.4 Completion of follow-up testing (occupational health metric).

5.0 REFERENCES

  • 5.1 CDC Sharps Safety Program Resources.
  • 5.2 CDC Sharps Safety Workbook (risk, prevention, exposure concepts).
  • 5.3 CDC Infection Control in Healthcare Personnel guideline (postexposure management).
  • 5.4 2025 U.S. Public Health Service HIV PEP recommendations (occupational context). (PMC)
Operating Theatre Policy

POLICY 13.8 — Visitors to Operating Room

Policy Code
Owner OT Director/Chair + OT Nurse Manager + Security + IPC
Related Policy 11.1 access, SEC 4 privacy, SEC 9 IPC zoning, Policy 11.11 photography
(Access, PPE, Privacy, Documentation)

1.0 PURPOSE | 2.0 POLICY STATEMENT

1.0 PURPOSE

1.1 To control and standardize visitor access to the operating room to protect patient privacy/dignity, maintain infection prevention controls, avoid distraction, and ensure accountability for who enters restricted zones.

2.0 POLICY STATEMENT

  • 2.1 The default rule is no visitors in the OR unless there is an approved purpose (training/education, vendor technical support, essential observation, rare family exception approved by leadership).
  • 2.2 Every visitor must have: approval, correct attire/PPE, supervision, and documented entry/exit.
  • 2.3 Visitors must comply with infection prevention rules; AORN transmission-based precautions guidance includes visitor PPE expectations when applicable (e.g., gown/gloves for contact precautions; mask for droplet/airborne). (Aorn.org)
  • 2.4 Photography/video by visitors is prohibited unless specifically authorized under Policy 11.11 with documented consent and approved storage.

3.0 PROCEDURE

3.1 Approval:

  • 3.1.1 Request approved by OT charge nurse and OT leadership (and IPC/security if needed).
  • 3.1.2 Purpose documented (education, vendor support, observation).

3.2 Patient privacy and consent:

  • 3.2.1 Ensure consent/permission where required by hospital policy (especially if visitor is not part of care team).
  • 3.2.2 Maintain Islamic culture dignity requirements (awrah protection, exposure minimization) consistent with SEC 4.

3.3 Attire/PPE:

  • 3.3.1 Visitors follow OT attire rules (scrubs, head covering, mask rules per restricted zone). AORN provides guideline-based expectations for OR attire. (Aorn.org)
  • 3.3.2 If transmission-based precautions apply, visitor PPE follows IPC direction (AORN guidance examples for visitor PPE). (Aorn.org)

3.4 Conduct:

  • 3.4.1 Visitors remain in assigned location, do not touch sterile field or equipment, and do not move around room.
  • 3.4.2 Visitors must leave immediately if: crowding increases, privacy risk occurs, staff request removal for safety/sterility.

3.5 Documentation:

  • 3.5.1 Visitor log includes name, role/company, purpose, supervisor name, time in/out, and PPE confirmation.
  • 3.5.2 Vendor presence in implant cases is cross-referenced to implant traceability processes (Policy 11.7).

3.6 Security:

3.6.1 Badges are visible; visitors escorted; access is limited to approved areas only.

4.0 AUDIT / KPIs | 5.0 REFERENCES

4.0 AUDIT / KPIs

  • 4.1 % visitors with complete log entries.
  • 4.2 Number of visitor-related disruptions or policy breaches.
  • 4.3 PPE compliance for visitors (spot audits). (Aorn.org)

5.0 REFERENCES

  • 5.1 AORN guidance on visitor PPE under transmission-based precautions. (Aorn.org)
  • 5.2 AORN surgical attire guideline summary (OR attire expectations). (Aorn.org)

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