Exhibit 11. Importance measures on events in rank order of criticality

Proactive Risk Assessment of Surgical Site Infection in Ambulatory Surgery Centers

EventCriticalityBirnbaumFussell–
Vesely
Event 642 Fail to protect patient effectively (failure related to skin prep, antibiotics admin, shaving surgical site, etc.)0.51870.01130.5187
Event 450 Obese, but not diabetic, patient (30 < BMI < 40)0.31470.00470.3147
Event 543 SSI risk for obese patient, weight not reduced and nutrition not improved0.30430.04090.3043
Event 173 Staff fails to provide patient with instructions for weight reduction0.30420.00150.3043
Event 142 Staff not well-trained in infection control0.25830.00380.2583
Event 182 Fail to administer indicated antibiotics0.23310.00510.2331
Event 677 Patient is a smoker but has no COPD0.20030.00700.2003
Event 456 Patient is a smoker and has COPD0.16490.01350.1649
Event 659 Glove puncture0.15500.00380.1550
Event 30 Fail to prepare skin appropriately0.14570.00510.1457
Event 138 Fail to remove watch/jewelry/fake nails0.12910.00380.1291
Event 644 Fail to re-administer antibiotics for longer surgery0.11660.00510.1166
Event 419 Patient fails to come for post-op visit0.11620.00340.1162
Event 136 Fail to wash hands properly (OR staff)0.103320.00380.1033
Event 687 Patient does not provide accurate info on smoking status0.09950.00120.0995
Event 241 Tourniquet time >60min0.09560.00510.0956
Event 660 Patient fails to notice infection during home care0.09290.00250.0929

Note: BMI = body–mass index; COPD = chronic obstructive pulmonary disease; OR = operating room

Return to Document

Page last reviewed April 2013
Internet Citation: Exhibit 11. Importance measures on events in rank order of criticality: Proactive Risk Assessment of Surgical Site Infection in Ambulatory Surgery Centers. April 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/final-reports/stpra/stpraexh11.html