Failures in safety protocols to reduce transmission of infectious agents

Editor's Note

This study from the University of Utah and University of Michigan found frequent and varied active failures in safety protocols to reduce infectious agent transmission by hospital personnel, including violations, mistakes, and slips.

Researchers identified 283 failures in safety protocols, including:

• 102 violations (deviations from safe operating practices or procedures)−such as, entering rooms without some or all recommended personal protective equipment (PPE)
• 144 process or procedural mistakes (failures of intention)−mistakes during PPE removal and encounters with challenging situations, such as badge-enforced computer logins
• 37 slips (failures of execution)−such as, touching one’s face or clean areas with contaminated gloves or gowns.

The factors that contributed to these failures varied not only across but within the different failure types, suggesting the need for strategies to reduce potential transmission risk during routine hospital care, the researchers concluded.