Lakeland Surgical & Diagnostic Center



OR/Procedure Room # _______

Date Cleaned _______

POLICY: Operating/procedure rooms are to be terminally cleaned (ceiling to floor) and this check list is to be completed by the cleaning crew or center support staff every night. The areas cleaned will be inspected by the staff assigned to each room prior to the start of cases the next day. This is to ensure the task has been completed and the appropriate level of terminal cleaning and disinfecting has taken place by those involved in the cleaning process. This evaluation tool is to be used to ensure that the quality of the services provided is acceptable.

PERFORMED BY: [Note: Identify who is responsible to clean the area.] The cleaning company or center support staff will perform terminal cleaning. The staff assigned to the room and general areas will check for completeness the next working day. If any deficiencies are noted, the completed form will be faxed to [insert cleaning company name] at [insert cleaning company fax #] or given to department manager for follow-up with those involved in the cleaning process. Rooms should be terminally cleaned daily regardless of whether a procedure was performed during the regular work week.


| |Initials of |INITials of |

| |PERSoN cleaning |pERSON INSPECTINg |

|1. Damp dust ceilings, surgical lights and tracks, fixed and ceiling-mounted equipment, AC | | |

|returns/vents, fire sprinklers, and ceiling. Anesthesia plugs and gas outlets are cleaned and | | |

|dusted. | | |

|2. Walls, doors, wall panels, suction wall mounts, x-ray view boxes, gas panels, wall outlets,| | |

|and Fire Extinguisher cages are cleaned and dusted | | |

|3. Glass, blinds, surface counters, cabinets and their handles, scrub sinks, ventilation face | | |

|plates, and all horizontal surfaces are cleaned, dusted, & spot free | | |

|4. All furniture, metal tables, foot pedals, telephones, step stools, light switches, OR exam | | |

|table, carts and unicels are thoroughly wiped down, clean and dusted | | |

|5. Sub-sterile room autoclave and warmer are dusted and lint free, and the floor is mopped, | | |

|cleaned, and spot free | | |

|6. All equipment has been moved and the floor in the operating/procedure room and hallway is | | |

|thoroughly swept and mopped. Floors should be wet-vacuumed after the last scheduled procedure | | |

|of the day or at least once during a 24-hour period. | | |

|7. Kick buckets and receptacles are cleaned and red bag liners replaced | | |

|8. Laundry and trash collection frames and lids are wiped clean | | |

|9. All trash and biohazardous waste has been removed and disposed of properly | | |


Adapted from Lakeland Surgical & Diagnostic Center, Lakeland, Fla.

DISCLAIMER: All data and information provided by the Oregon Patient Safety Commission is for informational purposes only. The Oregon Patient Safety Commission makes no representations that the patient safety recommendations will protect you from litigation or regulatory action if the recommendations are followed. The Oregon Patient Safety Commission is not liable for any errors, omissions, losses, injuries, or damages arising from the use of these recommendations.




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