In the Journals

Failures in transmission precautions for infectious agents common

Health care personnel in hospitals often made active failures, including violations, mistakes and slips, in personal protective equipment use and infectious agent transmission precaution practices that could potentially result in self-contamination, according to findings published in JAMA Internal Medicine.

“Using personal protective equipment and transmission-based precautions are primary strategies for reducing the transmission of infectious agents,” Sarah L. Krein, PhD, RN, from the VA Center for Clinical Management Research, Ann Arbor, Michigan, and colleagues wrote.

Krein and colleagues conducted a qualitative study to determine events that lead to failures in transmission-based precautions by health care personnel. The researchers completed 325 room observations in medical/surgical units, ICUs or EDs both inside (20.3%) and outside (79.7%) the room.

Trained observers recorded notes on number and types of failures related to transmission-based precautions during care sessions of patients requiring precautions for a pathogen transmitted through contact, including Clostridium difficile and MRSA, or respiratory droplet, including influenza.

Data showed that 283 failures occurred. Of those, 102 were violations, 144 were process or procedural mistakes and 37 were slips.

Violations were defined as deviations from safe operating practices or procedures and included entering rooms without some or all recommended personal protective equipment. Mistakes or failures of intention often occurred when health care personnel removed personal protective equipment and encountered difficult situations, such as badge-enforced computer logins. Slips defined as failures of execution or automatic behaviors often consisted of personnel touching their face or cleaning with contaminated gloves or gowns.

All types of failures were significantly likely to lead to self-contamination. The circumstances attributing to failures in precaution varied across and within the three failure types.

“Our assessment of active failures was not intended to call attention to the failed actions; instead, we wanted to identify the challenges faced by health care personnel that need to be addressed to promote effective [personal protective equipment] use,” Krein and colleagues concluded. “The broad array of contributing factors in each type of failure suggests that some circumstances may be more modifiable than others and that a range of strategies — behavioral, organizational, and environmental — may be needed to reduce the transmission risk during routine hospital care.”

In an accompanying editorial, Leora I. Horwitz, MD, MHS, from New York University School of Medicine, wrote that the study by Krein and colleagues highlights the value of direct field observations for patient safety.

“Without observation of real staff in real clinical scenarios, most of the failures identified in this study would go unrecognized, as would potential individual-level and systems-level fixes for them,” she wrote. “More such ethnographic and field studies are sorely needed.”– by Alaina Tedesco

Disclosure: The authors report no relevant financial disclosures.

Health care personnel in hospitals often made active failures, including violations, mistakes and slips, in personal protective equipment use and infectious agent transmission precaution practices that could potentially result in self-contamination, according to findings published in JAMA Internal Medicine.

“Using personal protective equipment and transmission-based precautions are primary strategies for reducing the transmission of infectious agents,” Sarah L. Krein, PhD, RN, from the VA Center for Clinical Management Research, Ann Arbor, Michigan, and colleagues wrote.

Krein and colleagues conducted a qualitative study to determine events that lead to failures in transmission-based precautions by health care personnel. The researchers completed 325 room observations in medical/surgical units, ICUs or EDs both inside (20.3%) and outside (79.7%) the room.

Trained observers recorded notes on number and types of failures related to transmission-based precautions during care sessions of patients requiring precautions for a pathogen transmitted through contact, including Clostridium difficile and MRSA, or respiratory droplet, including influenza.

Data showed that 283 failures occurred. Of those, 102 were violations, 144 were process or procedural mistakes and 37 were slips.

Violations were defined as deviations from safe operating practices or procedures and included entering rooms without some or all recommended personal protective equipment. Mistakes or failures of intention often occurred when health care personnel removed personal protective equipment and encountered difficult situations, such as badge-enforced computer logins. Slips defined as failures of execution or automatic behaviors often consisted of personnel touching their face or cleaning with contaminated gloves or gowns.

All types of failures were significantly likely to lead to self-contamination. The circumstances attributing to failures in precaution varied across and within the three failure types.

“Our assessment of active failures was not intended to call attention to the failed actions; instead, we wanted to identify the challenges faced by health care personnel that need to be addressed to promote effective [personal protective equipment] use,” Krein and colleagues concluded. “The broad array of contributing factors in each type of failure suggests that some circumstances may be more modifiable than others and that a range of strategies — behavioral, organizational, and environmental — may be needed to reduce the transmission risk during routine hospital care.”

In an accompanying editorial, Leora I. Horwitz, MD, MHS, from New York University School of Medicine, wrote that the study by Krein and colleagues highlights the value of direct field observations for patient safety.

“Without observation of real staff in real clinical scenarios, most of the failures identified in this study would go unrecognized, as would potential individual-level and systems-level fixes for them,” she wrote. “More such ethnographic and field studies are sorely needed.”– by Alaina Tedesco

Disclosure: The authors report no relevant financial disclosures.