Small Mistakes by Hospital Personnel Can Lead to Spread of Hospital Infections

August 13, 2018
Rachel Lutz

These mistakes can be as simple as a worker touching their face before removing contaminated gloves.

Sarah Krein, PhD, RN

The use and correct donning and doffing of personal protective equipment (PPE) presents a challenge in many health care facilities and new strategies to prevent the risk of infectious disease transmission, particularly in hospital settings, are sorely needed, according to a new study.

To identify and characterize the cause of failures in the use of PPE, investigators from Michigan and Utah, led by Sarah L. Krein, PhD, RN, from the Veterans Affairs Center for Clinical Management Research in Ann Arbor, Michigan, analyzed isolation precaution compliance through the use of PPE in multiple health care settings. A total of 16 acute care medical and/or surgical units, an emergency department, and 4 intensive care units (ICUs) within 2 medical centers—a university-based academic medical center, and a Veterans Affairs (VA) hospital—were observed from March 2016 to November 2016.

Trained observers collected field notes as part of their data while hospital personnel provided care for patients. Patients were on contact precautions for transmitted pathogens, such as Clostridium difficile and methicillin-resistant Staphylococcus aureus (MRSA), and/or droplet precautions for respiratory pathogens, such as influenza. Whenever a specific case of hospital personnel self-contamination was identified, a direct analysis took place. The investigators further quantified the results in terms of human factor models of human error: active failures such as violations, mistakes, or slips.

Across all sites during the study period, a total of 325 observations were made, of which 259 were made outside of a patient’s room, and 66 occurred inside the room.

The investigators reported 283 failures in care throughout their observations. Of these failures, there were 102 violations, defined as deviations from safe operating practices or procedures. Some common violations included entering rooms without some or all of the recommended PPE.

Observers identified 144 process or procedural mistakes, which the investigators called “failures of intention.” In this segment of failures, most were observed during the donning and doffing of PPE and encounters with procedural logistics (such as badge-enforced computer log ins).

There were 37 slips, which the study authors called failures of execution. They said that some of these examples were touching one’s face or clean areas while donning contaminated gloves or gowns.

As MD Magazine®’s sister publication Contagion® reported, “Violations were common during the “drop and dash” exchanges when health care workers entered the room without the intent of staying or touching anything and thought they could run into the room and run off. In their study, the investigators listed several examples of these violations (which are helpful to read if you’re looking for good examples of things we’re all guilty of doing).”

“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,” the study authors concluded.

In a related editorial, Leora I. Horwitz, MD, MHS, associate professor in the departments of population health and medicine at New York University School of Medicine, cited the 2002 acute respiratory syndrome outbreak in Asia and the 2014 Ebola virus outbreak in Africa as prime examples of health care workers properly using PPE. Those outbreaks infected thousands of health care workers.

“[In the United States and Europe, however] a combination of intensive training, ample equipment, rigorous protocols, direct observation, and triage of patients to specialized centers ensured that only 3 of the hundreds of health care workers [in those countries] who cared for 24 patients with Ebola infection…became infected,” Horwitz said.

About the new research, Horwitz suggested that the individual problems could be addressed through better or more targeted training; however, the constraints of health care setting practice often made mistakes inevitable, and correcting behaviors could prove challenging.

The paper, titled “Identification and Characterization of Failures in Infectious Agent Transmission Precaution Practices in Hospitals: A Qualitative Study,” was published in JAMA Internal Medicine.

Horwitz’s editorial was titled “The Importance of User-Centered Design and Evaluation Systems-Level Solutions to Sharp-End Problems,” and was also published in JAMA Internal Medicine.


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