Active Failures Seen in Proper Use of Personal Protective Equipment

Violations include entering rooms without some or all recommended personal protective equipment.
Violations include entering rooms without some or all recommended personal protective equipment.

HealthDay News — Active failures frequently occur in infectious agent transmission-based precautions, including personal protective equipment (PPE) use, according to a study published online June 11 in JAMA Internal Medicine.

Sarah L. Krein, PhD, RN, from the VA Ann Arbor Healthcare System in Michigan, and colleagues conducted a qualitative study involving direct observation inside and outside patient rooms in medical and/or surgical units and intensive care units at an academic medical center and Veterans Affairs hospital, as well as the emergency department of a university hospital. Through a directed content analysis, specific occurrences involving potential personnel self-contamination were identified by trained observers. 

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A total of 325 room observations were conducted at 2 sites; 79.7% occurred outside and 20.3% inside the room. The researchers observed 283 failures, including 102 violations, 144 process or procedural mistakes, and 37 slips. Violations included entering rooms without some or all recommended PPE; during PPE removal, mistakes were frequently observed, as well as during encounters with challenging logistical situations, such as badge-enforced computer logins. Touching one's face or clean areas with contaminated gloves or gowns were included as slips. The likelihood of resulting in self-contamination was considerable for each of these active failures.

"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 authors write.

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