Executive Summary of Surgical Site Infections
Patient safety and decreased mortality
The data show that while the facility may be performing at optimum levels in some areas there are indications for significant improvement in other areas. 100% compliance in all areas will have positive benefits for the patient as well as for the hospital. The goal is to improve compliance in order to ensure patient safety and decrease mortality rates for surgical patients.

Assessment
Appropriate hair removal and normathermia are two areas that show consistent compliance. Maintaining current processes and procedures is recommended.
While antibiotic selection was meeting the desired goal as set forth in the Surgical Care Improvement Project (SCIP) Inf-2, after May a significant decrease in compliance is noted. Use of prophylactic antibiotics prior to incision (SCIP Inf-1), stopping the antibiotic within 24 hrs. of surgery end time (SCIP Inf-3), beta blockers given during perioperative period (SCIP Card-2), recommended VTE prophylaxis ordered (SCIP VTE-1) and given within 24 hrs. prior through 24 hrs. after surgery (SCIP VTE-2)

Corrective Action Plan
The goal of the prophylactic antibiotic before and after surgery is to promote serum levels and gain bactericidal tissue. There is no known benefit for the patient to continue these antibiotics greater than 24 hrs. post-surgery (qualitymeasures.ahrq.gov, 2013). Physicians have been educated regarding the selection of antibiotics and the importance of administering the first dose within one hour of surgery (jointcommission.org, 2014). Concurrent audits to capture data in real time of these cases will help to ensure compliance by physicians in these two areas. Check lists, pre-printed order sets and pharmacy stocking the operating room with approved antibiotics will assist in maintaining compliance (medscape.org, 2006).