Module V: Safety

Root Cause Analysis of a Safety Problem

Problem Solving Using a Fishbone Diagram
A fishbone diagram is one method of finding the source or sources of a problem. It is a
systematic method of looking at various causes. It helps you to think outside your normal
thought patterns by suggesting other possible causes of a problem. Think of the diagram as a
cause and effect graph. Your problem is the effect. Now what is/are the cause(s)? (Fill in based
on your identified problem and add as an appendix to your paper)
Multiple number of people
in operating room

Breaking of aseptic
technique

Surgical Site Infection

Comorbidities
Surgical Technique

Now lets take some possible categories that are often the causes of problems and begin to fill out
the diagram.
Patient
Manpower
People entering and exiting
the operating room

Hygiene
Smoking

Too many people in the

operating room

The development of a
surgical site infection

Diabetes

Surgical hand antisepsis

Skin
Disinfection

Patient showering before surgery

Prophylactic antibiotic use
Surgical Technique
Bowel Prep
Hair removal
Methods

Surgical
Attire

Sterilization
equipment
Ventilation

Materials
Machines

Surgical Site Infection Problem Solving Using a Fishbone Diagram

Michael Phelps

BonSecours Memorial College of Nursing

October 25, 2014

According to The Center for Disease Control and Prevention, 1-3 out of every 100
patients that have had surgery may develop a surgical site infection. The CDC also defines a
surgical site infection as an infection that occurs in the part of the body where a surgical
procedure has taken place. (The Center for Disease Control and Prevention, 2014) Considering
certain guidelines dictating how hospitals are paid or reimbursed, hospitals are more than likely
determined to reduce or eliminate surgical site infections. In my opinion, the complete
elimination of a surgical site infection is not even possible at this moment. However, the
reduction of the number is possible.
After performing a fishbone diagram of a surgical site infection problem, I cannot
completely identify a specific cause of a surgical site infection. However, there are several
causes that may contribute to the problem of a surgical site infection. People, specifically, the
number of people and people entering and exiting the operating room during the procedure.
Breaks in aseptic technique, ensuring that all surgical personnel correctly cleans their hands and
arms with an antiseptic agent; as well as, making sure nothing happens to the surgical field that
breaks its aseptic manner. Comorbidities, certain patients are more prone to developing a
surgical site infection. And, the length of the operation, procedures that leave the wound open
for extended periods of time may be more prone to developing a surgical site infection.
There is one category that I would add to the causes on the fishbone diagram; the number
of bacteria present would be a possible cause. However, the number of bacteria has several
different variables. Does the wound have some contamination of some type? Is the wound open
before surgical incision was made? Is the wound dirty (pus, perforated gastric organ, or foreign
body in the wound? The number of bacteria raises another set of variables.
The problem statement is what causes a surgical site infection. Surgical site infections

can be caused by five categories with sub-topics in each category. One of those categories is
manpower, people going in and out of the room, too many people in the operating room in the
first place. Another category is methods, did the patient receive prophylactic antibiotics before
incision was made. Did the patient shower with an appropriate cleanser? Was appropriate
surgical hand antisepsis used? (Gould, 2012)Is correct surgical technique used during the
procedure? Did the patient receive or preform proper bowel prep? And, was hair removed prior
to incision of the site. Another category is materials, are people wearing appropriate surgical
attire? Outside clothing should never be worn in the operating room. Also, was appropriate skin
disinfection used prior to incision? Another category is machine, were the instruments used
during the procedure sterilized according to manufactures guidelines for correct sterilizer usage?
(The Centers for Disease Control and Prevention, 1999) And, is the ventilation system properly
exchanging the air in the operating room? (The Centers for Disease Control and Prevention,
1999) The final category is patient. Sometimes, all surgical precautions are taken and exhibited,
but some patients are just going to be prone to some type of infection. Does the patient have any
comorbidities that would lead to an infection? Patients with diabetes, especially those with
hyperglycemia being admitted, are at a greater risk for developing a surgical site infection than
non-diabetic patients. (American Academy of Orthopaedic Surgeons, 2012) Do they smoke?
Cigarette smoking can inhibit or delay wound healing, because it diminishes blood supply to
tissue. (Gould, 2012) Do they practice good hygiene habits?
Using the fishbone diagram, I cannot identify the root cause of my safety problem.
However, I could narrow down the cause if some categories can be eliminated during my
investigation. If I made sure ventilation was working properly, proper attire was worn in the
operating room. The proper disinfection agent was used by staff. The patient was not a smoker

or had comorbidities. That proper surgical technique and aseptic technique was used. I could
narrow the search for a probable cause of the surgical infection. However, there are a lot of
variable to go through, but it is still possible to find a problem.

Works Cited
American Academy of Orthopaedic Surgeons. (2012, July 25). High Blood Sugar, Obesity
Increases Risk for Surgical Site Infections. Retrieved from Sciencedaily.com:
http://www.sciencedaily.com/releases/2012/07/120725150213.htm
Gould, D. (2012, February 29). Causes, prevention adn management of surgical site infection.
Nursing Standard, pp. 47-55.
The Center for Disease Control and Prevention. (2014, October). FAQs about surgical site
infections. Retrieved from CDC.gov: http://www.cdc.gov/HAI/pdfs/ssi/SSI_tagged.pdf
The Centers for Disease Control and Prevention. (1999). Guidelines for Prevention of Surgical
Site Infections. Retrieved from CDC.gov: http://www.cdc.gov/hicpac/SSI/005_SSI.html
Wukich, D. K., McMillen, R. L., Lowery, N. J., & Frykberg, R. G. (2011). Surgical Site
Infections After Foot and Ankle Surgery. Diabetes Care, 2211-2212.