Infection Control Today

AUG 2018

ICT delivers to infection preventionists & their colleagues in the operating room, sterile processing/central sterile, environmental services & materials management, timely & relevant news, trends & information impacting the profession & the industry

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6 ICT August 2018 EDITORIAL EDITOR IN CHIEF Kelly M. Pyrek S ALE S/MARK E TING ACCOUNT EXECUTIVE Jay Franco SUBSCRIPTION CUSTOMER SERVICE 800-581-1811 PRODUC TION ART DIRECTOR Robert Rys AD PRODUCTION MANAGER Bonnie Streit DIRECTOR PUBLICATIONS Joseph Chackola HUMAN RESOURCES DIRECTOR Donna Layton INFORMA E XHIBITIONS LLC 2020 N. Central Ave., Ste. 400 Phoenix, AZ 85004 Phone: 480-867-7943 Web: editor's letter Kelly M. Pyrek Editor in Chief Protocol Breaches May Be Setting Up Healthcare Personnel for Failure S eeing that antibiotics are becoming less effective, the healthcare community is placing new emphasis on interventions and protocols to reduce the transmission of antibiotic-resistant organisms. However, assert researchers from the University of Utah and University of Michigan, hospitals may be setting up healthcare workers for failure. During 325 observations, researchers identified 283 protocol violations which could increase the risk of self-contamination of healthcare personnel and transmission of antibiotic-resistant organisms to patients. The study results were published in the June 11, 2018 issue of JAMA Internal Medicine. "We already know from other studies that there are breaches in practice," says fi rst author Sarah Krein, PhD, RN, research professor at the University of Michigan and research investigator at the Veterans Affairs Ann Arbor Healthcare System. "Our team was interested in understanding why and how those breaches occur so we can develop better strategies to ensure the safety of patients and healthcare personnel." During a nine-month period, 11 staff obser ved healthcare personnel at two locations. At one location, 280 observations were conducted in medical-surgical units (196), intensive care units (64) and the emergency department (20). At the second location, 45 observations were made in medical-surgical units (36) and intensive care units (9). "We were observing highly trained and motivated people working in a complex system that has issues," says Frank Drews, PhD, senior author on the paper. "We want to encourage healthcare decision-makers to make improvements to the system so it is easier for healthcare workers to adhere to best practices." The observation staff used Reason's model of human error to classify errors as violations, mistakes or slips. Violations occurred when personnel did not follow standard healthcare interaction protocols. Of the 102 violations, many occurred when the healthcare personnel did not put on the appropriate personal protective equipment, like gowns, gloves, and masks, because they did not plan to interact with the patient or the family. Other violations were observed when checking devices or dropping off supplies in patient rooms. Mistakes were classifi ed as errors in process or procedure. The 144 mistakes consisted of taking off gowns in the improper sequence, touching gloved hands to an ID badge to log into in-room computers and using gloved hands to retrieve medications or supplies from coat pockets. Finally, the observers classifi ed slips as inadvertent automatic behaviors. Of the 37 observed slips, the researchers identifi ed actions like healthcare personnel touching their face with a gloved hand or using personal devices. "At the core of our work is the idea that we need to be even more thoughtful about the type of equipment that we introduce in health care. More usable equipment will make it easier for health care workers to do their tasks and keep their patients safe," Drews says. "We want to make real fi xes to the system not just put a band-aide here or there." While this study identifi ed numerous errors, it suggests an opportunity to re-evaluate strategies that allow more latitude in current self-contamination and transmission protocols, such as redefi ning the area within the patient's room where protective clothing is required and reducing precaution requirements for some bacteria to ensure greater vigilance is applied to virulent organisms. Finally, many mistakes resulted from poorly designed clothing, room confi guration and computer access. The researchers note that the personnel in the study knew they were being observed, which may have lowered the number of violations observed. In addition, the results were obtained from 11 individuals who, despite receiving training, could have infl uenced the results with unintentional bias. While the study was conducted at two locations with different policies, recommended practices and products, similar issues were observed at both locations. Observers obtained verbal informed consent from patients and personnel prior to observations. Observations took place in two- to three-hour segments. Until next month, bust those bugs!

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