This projectís purpose is to address a concerning increase in the adult craniotomy surgical site infection (SSI) rate, identified by Infection Control & Prevention (IC&P) during the first six months of 2010. The SSI rate increased from 2.8 infections per 100 cases in late 2009 to 8.4 infections per 100 cases in the second quarter of 2010. A multidisciplinary task force (MTF) was formed, consisting of members from infection control, quality, sterile processing, perioperative education, neurosurgeons, anesthesia staff, and neuro manager and charge nurses. The MTF reviewed all relevant cases of post-craniotomy infections to identify common denominators. Next, they observed practice and mapped a process flow for craniotomies, identifying four major areas: hand scrub, sterile technique, head prep, and sterile wound dressing. Corresponding interventions included basic refresher training: hand scrub, maintaining sterile field, and sterilization of instrumentation; Lean methodology applied to remove unnecessary clutter and to reduce foot traffic in OR; adopted standard head prep: Chlorhexidine gluconate; and adopted standard wound dressing. Following interventions, the SSI rates among adult post-craniotomy patients decreased substantially with a low rate of 2.0 infections per 100 cases in the fourth quarter of 2010. Implications for Perioperative Nursing are that formation of a MTF, careful analysis, and reduction of intraoperative process variation may lead to SSI reduction.