Identification and Characterization of Failures in Infectious Agent Transmission Precaution Practices in Hospitals

A Qualitative Study
Importance: Using personal protective equipment (PPE) and transmission-based precautions are primary strategies for reducing the transmission of infectious agents.
Objective: To identify and characterize failures in transmission-based precautions, including PPE use, by health care personnel that could result in self-contamination or transmission during routine, everyday hospital care.
Design, Setting, and Participants: This qualitative study involved direct observation inside and outside patient rooms on clinical units from March 1, 2016, to November 30, 2016. Observations occurred in the medical and/or surgical units and intensive care units at an academic medical center and a Veterans Affairs hospital, as well as the emergency department of the university hospital. Trained observers recorded extensive field notes while personnel provided care for patients in precautions for a pathogen transmitted through contact (eg, Clostridium difficile, methicillin-resistant Staphylococcus aureus) or respiratory droplet (eg, influenza). Specific occurrences involving potential personnel self-contamination were identified through a directed content analysis. These occurrences were further categorized, using a human factors model of human error, as active failures, such as violations, mistakes, or slips.
Conclusions and Relevance: Active failures in PPE use and transmission-based precautions, potentially leading to self-contamination, were commonly observed. The factors that contributed to these failures varied widely, suggesting the need for a range of strategies to reduce potential transmission risk during routine hospital care.

Source: Krein, S. L., Mayer, J., Harrod, M., Weston, L. E., Gregory, L., Petersen, L., ... et Drews, F. A. (2018). JAMA Intern Med., 178(8), 1051-1057. http://dx.doi.org/0.1001/jamainternmed.2018.1898

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