Hospital staff racks up errors in infection transmission study

A study of 325 patient rooms found hospital staff frequently failed to take proper precautions to prevent the spread of infections.

The study, published in JAMA Internal Medicine, involved direct observation inside and outside patient rooms in clinical units from March to November 2016.

The observations took place 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 made field notes while hospital staff cared for patients in precautions for a pathogen transmitted through contact, such as Clostridium difficile and methicillin-resistant Staphylococcus aureus.

In the 325 room observations conducted at two sites, the researchers found 283 failures, including 102 violations (deviations from safe operating practices or procedures), 144 process or procedural mistakes (failures of intention) and 37 slips (failures of execution).

Violations included staff going into rooms without some or all recommended personal protective equipment. The researchers found mistakes frequently occurred during personal protective equipment removal and encounters with challenging situations, including badge-enforced computer logins. Slips included staff touching their face or clean areas with contaminated gloves or gowns.

The failures have significant potential to result in self-contamination, and the circumstances around these failures in precaution practices varied across and within the different failure types, the researchers said.

"Active failures in personal protective equipment use and transmission-based precautions, potentially leading to self-contamination, were commonly observed," the researchers wrote. "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."

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