Proactive Risk Assessment of Surgical Site Infection in Ambulatory Surgery Centers

Exhibit 9. Top five minimal cut sets for the basic case

Cut Set Contributed Probability Events Included in Cut Set
(Probability of Each Individual Event)
1 0.000103 Event 173 (0.9)

Staff fails to provide patient with instructions for weight reduction

Event 142 (0.3)

Staff not well-trained in infection control

Event 450 (0.293)

Obese, but not diabetic, patient
(30 ≤BMI <40)

Event 642 (0.2)

Fail to protect patient effectively (failure related to skin prep, antibiotics admin, shaving surgical site, etc.)

Event 182 (0.2)

Fail to administer indicated antibiotics

Event 543 (0.0325)

SSI risk for obese patient, weight not reduced and nutrition not improved

 
2 0.00006856 Event 173 (0.9)

Staff fails to provide patient with instructions for weight reduction

Event 450 (0.293)

Obese, but not diabetic, patient
(30 ≤BMI <40)

Event 660 (0.16)

Patient fails to notice infection during home care

Event 433 (0.05)

Patient has organism at postoperative visit

Event 543 (0.0325)

SSI risk for obese patient, weight not reduced and nutrition not improved

-
3 0.0000643 Event 173 (0.9)

Staff fails to provide patient with instructions for weight reduction

Event 142 (0.3)

Staff not well-trained in infection control

Event 450 (0.293)

Obese, but not diabetic, patient
(30 ≤BMI <40)

Event 642 (0.2)

Fail to protect patient effectively (failure related to skin prep, antibiotics admin, shaving surgical site, etc.)

Event 30 (0.125)

Fail to prepare skin appropriately

Event 543 (0.0325)

SSI risk for obese patient, weight not reduced and nutrition not improved

4 0.0000617 Event 173 (0.9)

Staff fails to provide patient with instructions for weight reduction

Event 450 (0.293)

Obese, but not diabetic, patient
(30 ≤BMI <40)

Event 642 (0.2)

Fail to protect patient effectively (failure related to skin prep, antibiotics admin, shaving surgical site, etc.)

Event 182 (0.2)

Fail to administer indicated antibiotics

Event 659 (0.18)

Glove puncture

Event 543 (0.0325)

SSI risk for obese patient, weight not reduced and nutrition not improved

5 0.0000514 Event 173 (0.9)

Staff fails to provide patient with instructions for weight reduction

Event 450 (0.293)

Obese, but not diabetic, patient (30<BMI<40)

Event 642 (0.2)

Fail to protect patient effectively (failure related to skin prep, antibiotics admin, shaving surgical site, etc.)

Event 182 (0.2)

Fail to administer indicated antibiotics

Event 138 (0.15)

Fail to remove watch/jewelry/fake nails

Event 543 (0.0325)

SSI risk for obese patient, weight not reduced and nutrition not improved

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Page last reviewed April 2013
Page originally created April 2013
Internet Citation: Exhibit 9. Top five minimal cut sets for the basic case. Content last reviewed April 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/final-reports/stpra/stpraexh9.html