Table 4.

Representative quotes developed from interview responses within the SEIPS* model.

Code	Theme	Representative Quote
Tools and technology
Barrier	Shortages of water, antiseptics, and gloves	“Most of the time, the supplies. No supplies most of the times. Maybe the gloves. Some gloves have powder and when we are not trying to glove, it may be not out.”
Facilitator	Instrument indicators	“There are indicators. They were autoclaved and the indicators are put externally and they change color. The way to see externally if it is dirty is observation. Both the indicators and observation.”
Organization
Barrier	Lack of IPC presence	“Why I said no, if there is an [IPC] as a figure, if they don’t work together with us working in the OR, it is not right to say there is an infection prevention team. And also…does not communicate with surgeons.”
Facilitator	SSI prevention checklist	“There is an infection prevention protocol. The protocol paper usually the scrub nurse will fill the protocol before starting the operation. Oh, a checklist? We draw the checklist. But we do not always have it”
Facilitator	Informal communication between wards and surgery	“Usually, we will communicate. If for example, I did the surgery and the patient has an infection and if she was diagnosed on the ward, he will tell him.”
Person
Barrier	Lack of training	“One important thing this infection prevention skills should be given or trained for the residents, for the nurses, and for the internists. There should be training. I stayed in this hospital for four years. Even a single day, nothing for infection prevention. But for all the residents and the internists and nurses, before they go to the OR room, they should have basic training at least techniques of scrubbing”
Facilitator	Motivation to prevent SSIs	“It is my duty. My responsibility…. should observe all the medical students, the residents, the surgeons, or someone else around. Should be observed for one who is contaminating or breaking sterility. If there is one who is breaking sterility you should tell him, you are contaminated.”
Task
Barrier	Emergency cases	“There are many emergency cases. I mean, it is the only one performing these surgeries…it is the catchment population for more than 15 million, you know, surgically speaking…so many difficulties come with.”
Barrier	Limited SSI tracking	“Yeah actually, this is difficult because the majority of them do not come back unless they have a major complication. For minor complaints, they will not come back. So, we don’t know how many percent of them develop surgical site infection really.”
Environment
Barrier	OR crowding and open doors	“Most of the time, the difficulty is that the doors should always be self- closing… If it is opened, one is forgetting to close and other people get into the OR… Most of the time, you are on surgery, when you turn about, someone is inside in the OR. There is a new person.”
Facilitator	Effective environmental service workers	“There are the cleaners. The cleaners are hard workers. Usually after transporting one patient from the table, they clean the room.”

Note. SEIPS, Systems Engineering Initiative for Patient Safety; OR, operating room; IPC, infection prevention and control.