Root Cause Analysis for Surgical Site Infection

ABSTRACT NUMBER: NESTAC_10

 

AUTHORS
Andrew Callaway,
Mr Andrew Bowey

AFFILIATIONS
Newcastle University Medical School

CORRESPONDING AUTHOR CONTACT EMAIL
moc.liamg@59yawallac.werdnA

MAIN ABSTRACT TEXT

Background
Surgical site infection is a significant and costly complication in spinal surgery. The Royal Victoria Infirmary spinal surgery department uses root cause analysis in each incidence of surgical site infection. Used in retrospect, the root cause analysis relies on documentation standards within the department being upheld. This audit focuses on documentation of intraoperative factors linked to infection: operative duration, blood loss, and normothermia.

Aim
Examine the adherence of record keeping practices in the Royal Victoria Infirmary spinal surgery department to its own standards for the completion of root cause analysis documents following surgical site infection.

Method
Data from 2018 was selected to reflect current practice.
Department root cause analysis documents were examined.
Data collected was compared to the standards:
-A RCA is completed in each incidence of SSI
-Operative duration is recorded
-Blood loss is recorded
-Patient temperature and warming device are recorded

Results
There were 20 recorded surgical site infections in 2018. Each incidence of infection had root cause analysis, of these 40% were complete in all examined criteria. All root cause analyses had documented operative duration. Patient temperature and record of warming device used were present in 75 and 70% of cases respectively. Blood loss was adequately documented in 55% of root cause analyses. Failure to use on objective measure (i.e. numerical) was a common fault in documentation of blood loss.

Conclusions
The standard for record of operative duration was upheld. Record of blood loss requires the most significant improvement. Objective measures should be favoured to subjective wherever possible.