The Agency for Healthcare Research and Quality commissioned in August 2010 a study with two primary objectives: using proactive risk assessment, to identify the realm of risk factors associated with surgical site infections resulting from procedures performed at ambulatory surgery centers; and to design an intervention to reduce the likelihood of such infections due the most common risk factors identified by the proactive risk assessment.
Prepared for the Agency for Healthcare Research and Quality under contract HHSA 290-06-00019i-12.
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Prepared by Laura A. Steighner, Ph.D., (Project Director), American Institutes of Health, Washington, DC; and Anthony D. Slonim, M.D., Dr.P.H. (Principal Investigator).
Chapter 1. Introduction
Chapter 2. ST-PRA Development
Overview of Sociotechnical Probabilistic Risk Assessment
Development of the Fault Tree Model
Chapter 3. Risk-Informed Interventions
Event(s) Targeted for Intervention
Chapter 4. Conclusions and Next Steps
Study Strengths and Limitations
Examining How to Make ST-PRA More Accessible
Appendix A. Literature Review
Appendix B. Database Analysis
Appendix C. Site Visit Protocol
Appendix D. Site Visit Process Comparison
Appendix E. Study Parameters
Appendix F. ST-PRA Fault Tree Model With Probability Estimates ( PDF version - 230.97 KB )
Appendix G. References for Fault Tree Model Probability Estimates
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The opinions presented here are those of the authors and do not necessarily reflect the position of the U.S. Department of Health and Human Services or the Agency for Healthcare Research and Quality.
We gratefully acknowledge the four local ambulatory surgery centers who took time out of their busy schedules to give our team a tour of their facilities and to answer a few questions about the "day in the life of a surgical patient." In addition, we would like to acknowledge Alex Alonso, PhD, for his guidance and support throughout the project, as well as Janan Musa for her quality assurance review of the final report.