JCAHO stuff..........

Specialties Operating Room


We have a small OR at our hospital....only 2 operating rooms and a GI Lab, and a 2 bed PACU, and we do our own sterile processing. We have never been JCAHO accredited, but are in the process of preparing for our first survey, and we need some input!

Does your facility keep a log book for logging specimins collected in surgery and sent to the lab?

Do you keep all medications locked? Or just narcotics?

(I checked on JCAHO website, and it doesn't appear this is necessary if they are "reasonable secure")

How are your Doc's coping with the new "time out" for site verification in your OR? (We have one that is totally refusing!)


171 Posts


All specs. are logged on our OR log as well as part of a triplicate pathology req. which goes with the speciman. Prior to keeping a paper copy of the OR log, the spec. was logged in to a journel with other pertinent data.

All our meds are to be locked in a cabinet when not used; especially any anesthesia meds. This was a big issue with JCAHO when they came last year.

Our doc's aren't thrilled but they comply with the time out.

good luck with your survey,



43 Posts

Thanks for your reply!

We have our first mock survey in November, and have never been JCAHO accredited before, so making lots of changes!:)

Appreciate your input!

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