PATIENT SAFETY

Surgical site infection safeguards

This example turns a surgical-site infection pathway into a barrier-based discussion. Contamination is the top event because it is the loss of control that occurs before infection or readmission. The left side identifies threats that can make contamination more likely and the practices intended to prevent it. The right side identifies clinical consequences and the recovery actions that can detect and limit harm. It is useful for a perioperative team reviewing how a patient moves from preparation through postoperative observation. Add local ownership, audit methods and escalation factors when the diagram is used in a formal safety review. It does not replace infection-prevention procedures, clinical assessment or patient-specific treatment decisions.

UPDATED 2026-09-24
TYPEBowtie
EXAMPLESurgical site infection safeguards
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CASE ANALYSIS

Scenario

Surgical safety review

Key decisions

  • Hazard: Keep the procedure context visible.
  • Top event: Use contamination rather than infection.
  • Prevention: Place sterile and timing controls on threat paths.
  • Recovery: Include surveillance and escalation after surgery.

When to reuse this

Use for a perioperative safety discussion and adapt it to local protocols.

FAQ

Frequently asked questions

Why is contamination the top event?01
It marks the point at which preventative controls have failed, before infection develops.
What belongs on the left?02
Threats and the barriers intended to stop them before contamination.
Who can use this diagram?03
Perioperative, infection-control and quality-improvement teams can use it as a shared review aid.
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