Study Identifies Multiple Failures in PPE Precautions for Infectious Agent Transmission; Suggests System Solutions

August 15, 2018 | Risk Management News

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​A study of healthcare staff compliance with contact and respiratory droplet precautions using personal protective equipment (PPE) found frequent and varied failures in infectious agent transmission precaution practices, suggesting that multiple strategies must be deployed to improve compliance. The study, published in the August 2018 issue of JAMA Internal Medicine, collected 325 observations of staff either outside or inside precaution rooms at two medical centers from March 2016 through November 2016. The researchers observed 283 failures and categorized them as 102 violations (deviations from safe operating practices, such as entering a patient room to talk to a patient without donning PPE), 144 mistakes (failures of intention, such as using an incorrect removal sequence for PPE), and 37 slips (failure of execution, such as healthcare personnel touching their face with contaminated gloves). No single strategy can effectively prevent these failures. Instead, a multi-pronged approach is needed that includes behavioral, organizational, and environmental solutions, the study authors say.

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