Governance Portal

Operating Theatre Policies & Procedures Manual

Front Matter

  • Title Page
  • Copyright / Disclaimer
  • Foreword
  • Acknowledgements
  • Standard Policy Template (Purpose / Scope / Definitions / Responsibilities / Procedure / Documentation / KPIs / References)
  • Master List of Policies (with codes)
  • Master List of Forms / Logs / Checklists (one list)

PART I — GOVERNANCE, LEADERSHIP, AND PROGRAM MANAGEMENT (GLD / QPS / SQE)

SEC 1 Operating Theatre Governance & Scope of Service

  • 1.1 OT Scope of Service (General / Specialty / Day Surgery / Obstetric OR if applicable)
  • 1.2 OT Organizational Structure & Reporting Lines
  • 1.3 OT Committee / Theatre Management Committee (TOR, membership, minutes)
  • 1.4 OT Policies Governance (create–review–approve–distribute–archive)
  • 1.5 Document Control & Staff Access
  • 1.6 OT Risk Register & Annual Safety Plan
  • 1.7 OT Capacity Planning, Case Prioritization, Escalation Pathway
  • 1.8 Outsourced Services Governance (CSSD interface, cleaning, vendors)

SEC 2 Workforce, Privileging Interface, and Competency (SQE)

  • 2.1 Credentialing/Privileging Interface (surgeons, OT nursing, OT techs)
  • 2.2 Scope of Practice: OT Nursing & Surgical Technologists
  • 2.3 OT Orientation Program & Departmental Induction
  • 2.4 Annual Competency Program (core + specialty)
  • 2.5 Mandatory Training Matrix (BLS/ACLS, Fire, IPC, Radiation, etc.)
  • 2.6 Staffing Model, Skill Mix, On-call Coverage
  • 2.7 Fatigue Management and Safe Scheduling
  • 2.8 Professional Conduct, Speaking-Up, Zero Tolerance
  • 2.9 Students/Observers and Supervision Rules

SEC 3 Quality, Patient Safety, and Audit System (QPS / IPSG)

  • 3.1 Patient Safety Program in OT (roles, safety rounds)
  • 3.2 Incident / Near-Miss / Hazard Reporting (OT responsibilities)
  • 3.3 Sentinel Event Response (RCA participation, action plans)
  • 3.4 OT Audit Program (counts, checklist compliance, IPC, meds labeling)
  • 3.5 OT KPI Dashboard (SSI bundle compliance, cancellation, utilization, etc.)
  • 3.6 Tracer Readiness & Mock Survey Plan
  • 3.7 Patient Feedback / Complaints Handling in OT
  • 3.8 Continuous Improvement (PDSA, reliability tools)

SEC 4 Ethics, Patient Dignity & Privacy in Operating Theatre (Islamic Culture) — ONE POLICY

  • 4.1 Privacy & “Awrah” protection during transfer, positioning, draping, recovery
  • 4.2 Gender sensitivity (chaperone rules, exposure minimization)
  • 4.3 Consent for exposure, photography/video, teaching/observers
  • 4.4 Confidentiality inside OT, voice/whiteboard/privacy screens
  • 4.5 Handling deceased patient in OT (dignity, transport, access control)
  • 4.6 Visitor limits and professional boundaries in OT
  • 4.7 Cultural/religious considerations (family communication, modesty, respect)

PART II — PATIENT FLOW: PRE-OP TO POST-OP (COP / IPSG / PCC)

SEC 5 Scheduling, Booking, and Pre-Operative Readiness

  • 5.1 Surgical Booking Process & Required Documentation
  • 5.2 Surgical Priority / Triage (elective, urgent, emergency)
  • 5.3 Day-of-Surgery Cancellation Criteria & Escalation
  • 5.4 Pre-op Checklist (ward/clinic readiness) (OT responsibilities only)
  • 5.5 Patient Preparation for OR (fasting verification, jewelry, skin prep confirmation)
  • 5.6 Blood product readiness & special equipment requests (OT coordination role)
  • 5.7 Transport to OT (handover, infection status, oxygen need as ordered)
  • 5.8 Patient Acceptance Criteria for OT

SEC 6 Patient Identification, Consent, and Procedure Verification (IPSG)

  • 6.1 Patient Identification (two identifiers)
  • 6.2 Informed Consent Verification (surgery, blood, implants — verification step)
  • 6.3 Site Marking Verification (including exceptions)
  • 6.4 Safe Surgery Process: Sign-In / Time-Out / Sign-Out (WHO checklist governance)
  • 6.5 Discrepancy Handling & Stop-the-Line Escalation
  • 6.6 Critical Information Communication (allergy alerts, isolation status, implants)
  • 6.7 Interpreter / Communication Support (workflow)

SEC 7 Handover and Transfers (OT responsibilities)

  • 7.1 Pre-op Handoff to OT (SBAR/I-PASS)
  • 7.2 Safe Transfer of Patient (trolley ↔ OT table, safe handling)
  • 7.3 OT On-Call System (activation, response time, responsibilities)

SEC 8 PACU / Recovery Room Interface — ONE POLICY ONLY

  • 8.1 Recovery Room Readiness + OT→PACU Handover (documentation + responsibility)

PART III — INFECTION PREVENTION & ENVIRONMENTAL CONTROL IN OT — ONE POLICY (PCI / FMS)

SEC 9 Infection Prevention & Control in Operating Theatre (Comprehensive Policy)

  • 9.1 OT zoning (unrestricted/semi-restricted/restricted)
  • 9.2 OT attire & dress code
  • 9.3 Traffic control / door opening discipline
  • 9.4 Hand hygiene + surgical hand scrub
  • 9.5 Sterile gowning
  • 9.6 Sterile gloving
  • 9.7 Surgical skin antisepsis
  • 9.8 Draping
  • 9.9 Maintaining sterile field & contamination response
  • 9.10 Isolation case workflow (PPE, routes, cleaning sign-off)
  • 9.11 Between-case cleaning & turnover (roles, agents, contact time)
  • 9.12 End-of-day / terminal cleaning
  • 9.13 Blood/body fluid spill management
  • 9.14 Equipment cleaning between patients
  • 9.15 Sterile supplies handling, storage, event-related sterility
  • 9.16 CSSD interface: point-of-use pre-cleaning, transport, loaner trays governance
  • 9.17 Linen handling & clean/dirty separation

PART IV — MEDICATION MANAGEMENT IN OT — ONE POLICY (MMU / IPSG)

SEC 10 Medication Management in Operating Theatre (OT Scope)

  • 10.1 Storage, security, temperature monitoring
  • 10.2 Labeling of prepared solutions/syringes on the sterile field
  • 10.3 LASA controls + segregation
  • 10.4 High-alert medication handling (OT double-check where applicable)
  • 10.5 Controlled medications kept in OT (endorsement, discrepancy escalation)
  • 10.6 Returns, wastage documentation, expiry checks
  • 10.7 Medication error reporting & learning loop

PART V — INTRA-OPERATIVE POLICIES (Independent Policies for Each Title) (IPSG / COP)

Note: This policy is split into three independent parts:
Part A — SEC 11 (11.1–11.3)  |  Part B — SEC 11 (11.4–11.7)  |  Part C — SEC 11 (11.8–11.13)

SEC 11 Intra-Operative Safety & Conduct

  • 11.1 OT Entry/Exit Control & Theatre Discipline
  • 11.2 Safe Practices in OT / Environmental Hazards / Wrong-Site Prevention
  • 11.3 Surgical Counts (sponges/sharps/instruments)
  • 11.4 Retained Surgical Item Prevention (count reliability + discrepancy process)
  • 11.5 Patient Positioning & Pressure Injury Prevention
  • 11.6 Specimen Handling, Labeling & Transport
  • 11.7 Implant / Prosthesis Traceability (stickers, logs, patient implant ID)
  • 11.8 Surgical Smoke Safety (smoke evacuation use, PPE, maintenance)
  • 11.9 Tourniquet Use (documentation, time/pressure recording, escalation) (if used)
  • 11.10 Contrast Media / Dyes Handling in OT (labeling, storage, documentation) (OT side)
  • 11.11 Clinical Photography/Video in OT (consent, privacy, storage controls)
  • 11.12 Perioperative Documentation Standards (OT record completion)
  • 11.13 Blood Loss Estimation & Documentation (OT documentation tool + escalation trigger)

PART VI — INSTRUMENTS, EQUIPMENT, AND TECHNOLOGY (HCT / FMS)

SEC 12 Surgical Instruments & Equipment

  • 12.1 Care & Handling of Instruments and Equipment
  • 12.2 Loaner Instruments / Vendor Trays Governance (tracking, completeness)
  • 12.3 Electrosurgical Unit (Diathermy) Safety
  • 12.4 Warming Cabinet Use & Safety
  • 12.5 Equipment Failure Response & “Remove from Service” Tagging
  • 12.6 Preventive Maintenance & Calibration Interface (biomed)
  • 12.7 Consumables & Expiry Management (sterile items, implants, sutures)
  • 12.8 IT Downtime Procedure (paper packs, back-entry rules)

PART VII — FACILITY SAFETY, SECURITY, AND STAFF SAFETY (FMS)

SEC 13 OT Facility Safety

  • 13.1 OT Safety Rounds & Hazard Reporting
  • 13.2 Fire Safety in OT: Prevention & Response
  • 13.3 Medical Gas Safety (pipeline awareness, cylinder handling — OT scope)
  • 13.4 Electrical Safety & Equipment Plug Rules
  • 13.5 Radiation Safety in OT (C-arm workflows, PPE, badges — OT scope)
  • 13.6 Waste Segregation (sharps, clinical, cytotoxic, general)
  • 13.7 Sharps Injury Prevention & Exposure Response (OT workflow)
  • 13.8 Visitors to Operating Room (access, PPE, privacy, documentation)

PART VIII — EMERGENCY & BUSINESS CONTINUITY (FMS / IPSG)

SEC 14 OT Emergency Coordination (OT Scope)

  • 14.1 Code Blue / Rapid Response Activation in OT (roles + access + crowd control)
  • 14.2 Massive Hemorrhage Activation (OT logistics, equipment readiness, documentation)
  • 14.3 OT Evacuation / Shelter-in-Place
  • 14.4 Utility Failure Contingency (power/medical gases/IT downtime response)
  • 14.5 Infectious Outbreak / Surge OT Workflow (routes, zoning, terminal cleaning)

PART IX — SPECIALTY OT WORKFLOWS

SEC 15 Specialty Operating Theatre Workflows

  • 15.1 Emergency / Trauma OR Workflow (OT readiness + activation)
  • 15.2 Obstetric Theatre Workflow (OT side: readiness, instruments, counts, specimens)
  • 15.3 Pediatric Surgery Workflow (OT side: equipment, warming, counts)
  • 15.4 Orthopedic Implant Surgery Workflow (traceability, loaner trays, counts)
  • 15.5 ENT / Shared Airway Field (OT side: smoke, sharps, specimen, counts)

MASTER LIST — FORMS / LOGS / CHECKLISTS

F-OT-01 Operation Lists / 24-Hour OT List (24 HOURS OT LIST / OPERATION LIST)
F-OT-02 Pre-Operative Checklist (CLUSTER PRE-OPERATIVE CHECKLIST)
F-OT-03 Safe Surgery/Procedure Checklist (WHO) (CLUSTER SURGICAL SAFETY)
F-OT-04 Sponges/Sharps/Instruments Count Form (CLUSTER COUNTS)
F-OT-05 Combined Safe Surgery + Counts (CLUSTER SURGICAL SAFETY AND COUNTS)
F-OT-06 Blood Loss Form (CLUSTER BLOOD LOSS FORM)
F-OT-07 Histopath / Specimen Form (CLUSTER NEW HISTOPATH FORM)
F-OT-08 Doctor’s Notes Form (CLUSTER DOCTORS NOTES)
F-OT-09 Policies/Procedures Tracker Form (TRACKER FORM FOR THE POLICIES AND PROCEDURES)
F-OT-10 Narcotic Drug Endorsement Form (NARCOTIC DRUG ENDORSEMENT FORM)
F-OT-11 Narcotic Monitoring List (NARCOTIC DRUGS – e.g., fentanyl list)
F-OT-12 OT Cancellation Form + Reason Codes
F-OT-13 OT On-Call Activation Log
F-OT-14 OT→PACU Handover Checklist
F-OT-15 Specimen Chain-of-Custody Log
F-OT-16 Implant Traceability Form / Implant Stickers Log (linked to 11.7)
F-OT-17 Tourniquet Record (time/pressure/limb/signatures) (linked to 11.9)
F-OT-18 Diathermy Safety Checklist
F-OT-19 Warming Cabinet Temperature Log
F-OT-20 OR Temperature/Humidity Log (PCI/FMS expectation)
F-OT-21 Between-Case Cleaning Checklist + Terminal Cleaning Sign-off (inside IPC policy)
F-OT-22 Visitor Log (name, reason, PPE, consent/privacy acknowledgement) (linked to & Ethics policy)
F-OT-23 Photography/Video Consent Form (linked to 11.11 & Ethics policy)
F-OT-24 Fire Drill Evaluation Form
F-OT-25 Equipment “Remove from Service” Tag + Failure Report Slip (linked to Part VI)