Identification and characterization of failures in infectious agent transmission precaution practices in hospitals

Health care personnel in hospitals often made active failures in personal protective equipment (PPE) use and infectious agent transmission precaution practices, a new study shows. According to a team led by Sarah L.

Health care personnel in hospitals often made active failures in personal protective equipment (PPE) use and infectious agent transmission precaution practices, a new study shows. According to a team led by Sarah L. Krein, PhD, RN, from the VA Center for Clinical Management Research, Ann Arbor, MI, the lapses included violations in practice as well as procedural mistakes and unintentional slips. The qualitative study involved direct observation inside and outside patient rooms in the medical and/or surgical units and ICUs at an academic medical center and a Veterans Affairs hospital, and also at the emergency department of the university hospital. Overall, there were 325 room observations at two sites, with about 80% occurring outside and about 20% inside the room. Of the 283 failures observed, there were 102 violations (deviations from safe operating practices or procedures), 144 process or procedural mistakes (failures of intention), and 37 slips (failures of execution). "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 PPE use," the researchers write. "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."