VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan.
Department of Internal Medicine, University of Michigan, Ann Arbor.
JAMA Intern Med. 2018 Aug 1;178(8):1016-1057. doi: 10.1001/jamainternmed.2018.1898.
Using personal protective equipment (PPE) and transmission-based precautions are primary strategies for reducing the transmission of infectious agents.
To identify and characterize failures in transmission-based precautions, including PPE use, by health care personnel that could result in self-contamination or transmission during routine, everyday hospital care.
DESIGN, SETTING, AND PARTICIPANTS: This qualitative study involved direct observation inside and outside patient rooms on clinical units from March 1, 2016, to November 30, 2016. Observations occurred 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 recorded extensive field notes while personnel provided care for patients in precautions for a pathogen transmitted through contact (eg, Clostridium difficile, methicillin-resistant Staphylococcus aureus) or respiratory droplet (eg, influenza). 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 error, as active failures, such as violations, mistakes, or slips.
Number and type of failures involving use of transmission-based precautions.
In total, 325 room observations were conducted at 2 sites. At site 1, a total of 280 observations were completed (196 in medical/surgical units, 64 in intensive care units, and 20 in emergency departments). At site 2, there were 45 observations (36 in medical/surgical units and 9 in the intensive care unit). Of the total observations, 259 (79.7%) occurred outside and 66 (20.3%) inside the room. Two hundred eighty-three 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). Violations involved entering rooms without some or all recommended PPE. 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 within the different failure types.
Active failures in PPE use and transmission-based precautions, potentially leading to self-contamination, were commonly observed. 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.
使用个人防护设备（PPE）和基于传播的预防措施是减少传染病原体传播的主要策略。
确定并描述卫生保健人员在基于传播的预防措施（包括 PPE 使用）方面的失败，这些失败可能导致在常规日常医院护理过程中自我污染或传播。
设计、地点和参与者：这项定性研究包括 2016 年 3 月 1 日至 11 月 30 日在学术医疗中心和退伍军人事务医院的内科和/或外科病房以及大学医院的急诊室进行的临床单元内和单元外的直接观察。经过培训的观察员在工作人员为接触传播（例如艰难梭菌、耐甲氧西林金黄色葡萄球菌）或呼吸道飞沫（例如流感）病原体提供预防措施时，记录了大量实地笔记。通过有针对性的内容分析，确定了涉及潜在人员自我污染的特定事件。使用人为错误的人为因素模型对这些事件进行了进一步分类，分为主动故障，例如违规、错误或失误。
涉及使用基于传播的预防措施的故障数量和类型。
在两个地点共进行了 325 次房间观察。在地点 1，共完成了 280 次观察（196 次在医疗/外科病房，64 次在重症监护病房，20 次在急诊室）。在地点 2，有 45 次观察（36 次在医疗/外科病房，9 次在重症监护病房）。在总共的观察中，259 次（79.7%）在房间外进行，66 次（20.3%）在房间内进行。观察到 283 次故障，包括 102 次违规（违反安全操作规范或程序），144 次过程或程序错误（意图失败）和 37 次失误（执行失败）。违规行为涉及在没有某些或所有推荐的 PPE 的情况下进入房间。在 PPE 移除过程中以及在面临具有挑战性的后勤情况（例如徽章强制计算机登录）时经常观察到错误。失误包括用污染的手套或长袍触摸自己的脸或清洁区域。这些主动故障中的每一个都有很大的可能性导致自我污染。然而，预防措施中的故障情况不仅在不同的故障类型之间有所不同，而且在同一类型的故障中也有所不同。
普遍观察到 PPE 使用和基于传播的预防措施中的主动故障，可能导致自我污染。导致这些故障的因素差异很大，这表明需要采取一系列策略来降低常规医院护理过程中的潜在传播风险。
