Study Spotlights Common Infection Transmission Mistakes Made by Hospitals

A new study of patient rooms published in JAMA Internal Medicine identified common infection transmission mistakes made by hospital personnel. The study looked at 325 patient rooms with precaution signage and found a variety of failures in infectious agent transmission precaution practices.

Researchers observed 283 failures, 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 included entering rooms without some or all recommended personal protective equipment (PPE). Mistakes were often observed during PPE removal and encounters with challenging situations, such as badge-enforced computer logins. Slips included workers touching their face or clean areas with contaminated gloves or gowns. Each of these failures has a substantial likelihood of resulting in self-contamination, according to researchers Sarah L. Krein, PhD, RN, Jeanmarie Mayer, MD, and Molly Harrod, PhD.

The study recommends that organizations implement a range of strategies to reduce potential transmission risk during routine care, including use of PPE and transmission-based precautions.