Mistakes Causing Self-contamination Common in Hospitals

Pam Harrison

June 13, 2018

Failures to don personal protective equipment (PPE) and adhere to routine precautions to prevent transmission of infectious agents are common in hospitals and are a source of potential self-contamination, a qualitative study suggests.

"Standard and transmission-based precautions are an infection-prevention mainstay for protecting patients and health care personnel, " Sarah Krein, PhD, RN, VA Ann Arbor Healthcare System in Michigan, and colleagues report. "Our findings identify several active failures in PPE use and precaution practice during routine hospital care that could result in self-contamination or transmission."

"Understanding the types of failures and the context in which failures occur is essential for effectively mitigating the risk of pathogen transmission," the researchers continued in an article published online June 11 in JAMA Internal Medicine.

For 9 months, researchers directly observed healthcare personnel both outside and inside patient rooms that were clearly signed for workers to take precautions against pathogen transmission. "Observations occurred on 16 acute care medical and/or surgical units and 4 intensive care units (ICUs) at 2 medical centers, a university-based academic medical center...and a Veterans Affairs (VA) hospital...as well as the emergency department at the university-based medical center," the researchers explain.

Investigators made a total of 325 observations across both study sites, 79.7% of which occurred outside the room and 20.3% of which occurred inside the room.

Overall, the researchers observed 280 safety failures.  Most (72.9%) of the observed failures involved missteps with contact precautions, and each failure had the potential for self-contamination either directly or indirectly.

The authors distinguished between three different types of errors: violations (n = 102), which included purposeful deviations from policy; mistakes (n = 144), which occurred while personnel tried to follow policy; and slips (n = 37), which were automatic behaviors that increase the risk for self-contamination.

Violations ranged from healthcare personnel entering the room without donning PPE or using PPE improperly, with gowns not tied, for example. "A common scenario was personnel entering a room without any PPE, including gloves, which were required at room entry for all precaution types," investigators explained.

Even though healthcare personnel may have come into a room with no intention of making any contact, "their encounters often resulted in contact with the patient or the patient environment," researchers observe. For example, a physician not wearing gloves might touch a button on a machine at the end of bed, a violation of contact precautions.

Another example of a violation included a nurse entering a room carrying an incontinence bed pad and tucking that pad underneath the patient and then entering into a discussion with the patient while leaning against a bedrail, again with ungloved hands.

Mistakes or Errors of Intent

Unlike violations,  mistakes were characterized as "errors of intent." These were frequently observed when healthcare workers were trying to remove PPE. For example,  a healthcare worker  trying to remove their PPE while holding an object such as a binder, which would leave them holding the binder against an ungowned — and unprotected — section of clothing. 

Another example of a mistake was a healthcare worker removing PPE in the wrong sequence, such as taking eye protection and a mask off with the gloves still on. Other opportunities for self-contamination emerged when workers were forced to use a badge to log onto in-room computers or to reach underneath a gown to retrieve a stethoscope and then, after examining the patient, wrapping the stethoscope around his or her neck where it dangled over the gown.

Automatic Behaviors Can Increase Risk

"The third type of commonly observed active failure comprised highly automatic behaviors or slips," Krein and colleagues observe. Though seemingly innocuous, slips again resulted in a "high likelihood" of self-contamination.

Some of the most common "slips" involved healthcare personnel touching their face with contaminated gloves, or pushing up their glasses or wiping sweat from their face, again while wearing contaminated gloves. Healthcare workers were also prone to using their personal devices, such as a cell phone, which required them to retrieve the device from their pocket, answer it, then put it back into their pocket, another violation of contact precautions.

"These automatic responses usually appeared to be instinctual actions and not

intentional breaches, but there was a high likelihood of potential transmission," the authors observe. "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," they conclude.

Perceived Low Risk

Commenting on the study, editorialist Leora Horwitz, MD, NYU School of Medicine, New York City, suggests that healthcare personnel appear to be avoiding the use of PPE deliberately because they think they are at low risk for self-contamination and transmission of infectious agents.

She notes that while it would have been helpful to know the rate of safety failures in the study, having the detailed description of errors is very helpful.

"To globally reduce these kinds of violations, infection control epidemiologists will need either to change health care workers' risk calculus by making the actual risk of contact more evident (ie, by specifically orienting training to demonstrate that unintentional contact is frequent even in these just-stopping-in-to-chat situations...or to change systems-level infection control policies if these situations are determined to be sufficiently low risk that PPE can be avoided," she writes.

What hospitals have to do is address circumstances where violations of protocol occur because healthcare personnel have little choice but to place themselves at risk for self-contamination.

For example, most hospitals don't give personnel any option to leave a clipboard outside a room so that it isn't brought inside a room. Nor do hospitals typically provide disposable stethoscopes or readily accessible wipes in rooms. "In-room computers should not require badge log-in," Horwitz also suggests.

In addition, "training should explicitly include...common lapses [or slips], helping clinicians to be mindful of them and to potentially lessen their frequency," she writes.

What hospitals must not do, though, is ignore violations and allow them to continue.  "Allowing the status quo to remain — in which individuals are aware that they are violating policy but do so anyway — breeds an insidious culture of routine protocol violation often termed normalization of deviance, which can have global adverse consequences for safety," Horwitz emphasizes.

The study was funded by the Centers for Disease Control and Prevention and the VA Health Services Research and Development Service. The authors and editorialist have disclosed no relevant financial relationships .

JAMA Intern Med. Published online June 11, 2018. Abstract, Editorial

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