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5 Hidden Causes of SSIs

Publish Date: 4/18/2012

Surgical site infections are dangerous, costly and – sadly - preventable. They kill an estimated 8,000 people a year and comprise 22 percent of health care acquired infections, according to CDC data from 2009. They’re also in the spotlight since CMS in January began requiring that inpatient facilities publicly report SSIs associated with hysterectomies and colon surgeries.

Clinicians often look at specific clinical missteps identifying the cause of SSIs.

But behind every “active” failure are many “latent” or system failures, says Shelby Lassiter, RN, BSN, CPHQ, CIC, performance improvement specialist with the North Carolina Center for Hospital Quality and Patient Safety.  

Think of it this way: human error is not a failure, but it’s a symptom of a system failure. Latent failures set the stage for active failures, and can be thought of as the “error behind the error.”  Some hidden causes of SSIs include: 

  1. Poor placement of hand sanitizers. It’s no secret that incomplete hand hygiene contributes to SSIs. But one cause of inadequate hand hygiene may be the location or color of hand gel dispensers in the OR. “Are they readily available on both sides of the room?” asks Lassiter. “Are the gel dispensers beige, so they blend into the wall making them hard to find? Are they in different locations in each OR, so staff have to look around to find them?”
  2. Faulty scheduling /chronically late surgeons or staff. If personnel vital for the surgery are chronically late, everyone is in “wait mode,” notes Lassiter.  “Scrub nurses may sit down and the moment they do, they become contaminated.”

    If your facility suffers from this problem, you may need to do further digging. Are surgeries being scheduled too close together? Why are particular surgeons often late for their cases? Knowing the root cause is the first step towards a solution.
  3. An authoritarian culture. In some ORs, ‘what the surgeon says, goes.’ But “even the most junior person, like the housekeeper, should feel comfortable speaking up, and everyone in the chain of command should feel comfortable hearing it,” Lassiter says. “Research shows that any time there is not a sense of psychological safety, there’s an increased risk of error.”

    Hand in glove, an authoritarian culture breeds a lack of accountability and responsibility in the team members.  If people feel they don’t make a difference, their standards can slip. “This is a risk in the OR because we are not often aware of the consequences of our actions,” Lassiter adds. “The outcome – an SSI – is separated in time from our actions.”
  4. Inappropriate PPE: Although AORN standards call for covering all hair in the OR, some staff and surgeons still wear skull caps, don’t tie masks tightly enough or fail to cover facial hair completely. “Hair has a high level of dander that can fall onto the surgical site,” Lassiter notes. “And if your mask is loose, breathing directly on the surgical site can disperse germs and inoculate the wound.”
  5. Busy OR traffic. The surgeon’s partner opens the door and shouts in a comment. A sales rep wanders in.  Residents walk by. People break for lunch.

    The more traffic, the more shedding of skin cells and airflow turbulence, all of which can contribute to SSIs, Lassiter says.  Although we all know it’s wrong, it becomes the ‘standard way of doing things’ at many hospitals. “And we need to be able to speak up and say, ‘hey, you shouldn’t be in here.’” Lassiter adds.

Too often, these hidden causes lead to less-than-optimal behaviors that compromise patient safety. It becomes, ‘what do we tolerate?’ rather than ‘what’s right?”

“Culture is what you do when nobody is looking and you’re under the gun,” Lassiter concludes. “A culture of safety is what we’d want done if we –or our babies - were the ones undergoing surgery.”

Other Resources

For more information about defect analysis and SSIs, attend the AORN eCongress education session on ”Where the Wild Things Are Causing SSIs” by Lassiter and Sharon A. McNamara, MSN, RN, CNOR, perioperative consultant, North Carolina Center for Hospital Quality and Patient Safety.  Learn more or go here to register.



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