Are Hospital Staff Failing to Practice Transmission-Based Precautions?

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Active failures in personal protective equipment use by healthcare personnel may potentially lead to self-contamination.

Active failures in personal protective equipment (PPE) use and transmission-based precautions by healthcare personnel may potentially lead to self-contamination, according to a study recently published in JAMA Internal Medicine.

Preventing the spread of infectious organisms is a priority for hospitals and healthcare systems. Standard and transmission-based precautions are an infection-prevention mainstay for protecting patients and healthcare personnel. These precautions include hand hygiene and the use of special clothing or equipment known as PPE.

Although noncompliance is documented in numerous studies, the potential failures and the circumstances surrounding failures in precaution practices are not well described in the literature. 

Understanding the types of failures and the context in which failure occurs is essential for effectively mitigating the risk for pathogen transmission. Therefore, this qualitative study aimed to identify and characterize failures in transmission-based precautions, including PPE use, by healthcare personnel that could result in self-contamination or transmission during routine, everyday hospital care.

The main outcome of this study was the number and type of failures involving use of transmission-based precautions. Between March and November f 2016, a total of 325 direct observations inside and outside patient rooms on clinical units were conducted at either an academic medical center or a Veterans Affairs hospital in the medical and/or surgical units, intensive care units, or emergency department.

At site 1, a total of 280 observations were completed, including: 196 in medical/surgical units, 64 in intensive care units, and 20 in emergency departments. At site 2, a total of 45 observations were completed, including 36 in medical/surgical units and 9 in the intensive care unit.

Trained observers recorded extensive field notes and personnel provided care for patients in precautions for a pathogen transmitted through contact or respiratory droplet.

Specific occurrences involving potential personnel self-contamination were identified through a directed content analysis. These occurrences were further categorized, using a human factors model of human errors, as active failures, such as violations, mistakes, or slips.

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Of the total observations, 79.7% occurred outside and 20.3% inside the room. Overall, 283 failures were observed, including 102 violations (deviations from safe operating practices or procedures), 144 process or procedural mistakes (failures of intention), and 37 slips (failures of execution). Observed violations involved entering rooms without some or all recommended PPE.

In addition, mistakes were frequently observed during PPE removal and encounters with challenging logistical situations, such as badge-enforced computer logins. Slips included touching one’s face or clean areas with contaminated gloves or gowns. Each of these active failures has a substantial likelihood of resulting in self-contamination. The circumstances surrounding failures in precaution practices, however, varied not only across but also within the different failure types.

The study authors concluded that, “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.”


Krein SL, Mayer J, Harrod M, et al. Identification and characterization of failures in infectious agent transmission precaution practices in hospitals, a qualitative study [published online June 11, 2018]. JAMA Intern Med. doi: 10.1001/jamainternmed.2018.1898