Identification and characterization of failures in infectious agent transmission precaution practices in hospitals: a qualitative study.

Sarah L. Krein; Jeanmarie Mayer; Molly Harrod; Lauren E. Weston; Lynn Gregory; Laura Petersen; Matthew H. Samore; Frank A. Drews

Study

Emerging Classic

Identification and characterization of failures in infectious agent transmission precaution practices in hospitals: a qualitative study.

June 20, 2018

Krein SL, Mayer J, Harrod M, et al. JAMA Intern Med. 2018;178(8):1016-1057.

View more articles from the same authors.

Infection control precautions including use of personal protective equipment (PPE) are critical for preventing transmission of infections within health care settings. This direct observation study observed frequent failures in use of PPE, including entering rooms without using PPE at all, PPE process mistakes, and slips in properly executing PPE use. The authors suggest that given the wide range of failures, a variety of strategies are needed to improve use of PPE.

PubMed citation

Free full text

Related editorial

Related Resources From the Same Author(s)

It's like sending a message in a bottle: a qualitative study of the consequences of one-way communication technologies in hospitals.

October 13, 2021

Factors influencing physician responsiveness to nurse-initiated communication: a qualitative study.

December 2, 2020

Focused ethnography of diagnosis in academic medical centers.

May 9, 2018

Formative evaluation of the video reflexive ethnography method, as applied to the physician–nurse dyad.

February 6, 2019

Electronic health records, communication, and data sharing: challenges and opportunities for improving the diagnostic process.

August 14, 2019

Understanding diagnostic errors in medicine: a lesson from aviation.

June 21, 2006

Risk factors for adverse drug events: a 10-year analysis.

June 8, 2005

Interpersonal and organizational dynamics are key drivers of failure to rescue.

December 5, 2018

Checking the lists: a systematic review of electronic checklist use in health care.

November 23, 2016

Clarifying adverse drug events: a clinician's guide to terminology, documentation, and reporting.

March 6, 2005

Using incident reports to assess communication failures and patient outcomes.

April 17, 2019

Preventing device-associated infections in US hospitals: national surveys from 2005 to 2013.

June 3, 2015

The importance of leadership in preventing healthcare–associated infection: results of a multisite qualitative study.

September 15, 2010

How active resisters and organizational constipators affect health care–acquired infection prevention efforts.

April 13, 2011

The influence of organizational context on quality improvement and patient safety efforts in infection prevention: a multi-center qualitative study.

November 10, 2010

Advancing patient safety through the clinical application of a framework focused on communication.

December 19, 2018

A cognitive task analysis of information management strategies in a computerized provider order entry environment.

November 29, 2006

Detection and prevention of medication errors using real-time bedside nurse charting.

August 31, 2005

Mind the overlap: how system problems contribute to cognitive failure and diagnostic errors.

October 24, 2018

Enhancing the effectiveness of team debriefings in medical simulation: more best practices.

March 11, 2015

Toward the development of the perfect medical team: critical components for adaptation.

March 17, 2021

Preventing hospital-acquired infections: a national survey of practices reported by U.S. hospitals in 2005 and 2009.

December 21, 2011

Clostridium Difficile infection in the United States: a national study assessing preventive practices used and perceptions of practice evidence.

May 20, 2015

Healthcare personnel attire in non–operating-room settings.

February 12, 2014

Measuring errors and adverse events in health care.

March 6, 2005

What US hospitals are currently doing to prevent common device-associated infections: results from a national survey.

May 8, 2019

Disclosure of adverse events and errors in surgical care: challenges and strategies for improvement.

June 4, 2014

Not overstepping professional boundaries: the challenging role of nurses in simulated error disclosures.

September 21, 2011

A systematic review of team training in health care: ten questions.

March 8, 2017

Explainable artificial intelligence for safe intraoperative decision support.

September 25, 2019

Prescription errors and outcomes related to inconsistent information transmitted through computerized order entry: a prospective study.

June 3, 2009

Pending studies at hospital discharge: a pre-post analysis of an electronic medical record tool to improve communication at hospital discharge.

January 7, 2015

Saving lives: a meta-analysis of team training in healthcare.

August 3, 2016

Introducing the patient safety professional: why, what, who, how, and where?

September 28, 2011

The effect of medical emergency teams on patient outcome: a review of the literature.

January 5, 2011

Errors in cancer diagnosis: current understanding and future directions.

December 19, 2007

A simulation-based evaluation of methods to estimate the impact of an adverse event on hospital length of stay.

October 24, 2007

Responding to patient safety incidents: the "seven pillars."

April 7, 2010

Impact of extended-duration shifts on medical errors, adverse events, and attentional failures.

December 13, 2006

Am I safe here? Improving patients' perceptions of safety in hospitals.

January 25, 2006

A prospective cohort study of medication reconciliation using pharmacy technicians in the emergency department to reduce medication errors among admitted patients.

January 21, 2015

Readmission after delayed diagnosis of surgical site infection: a focus on prevention using the American College of Surgeons National Surgical Quality Improvement Program.

August 13, 2014

Surveillance of medical device-related hazards and adverse events in hospitalized patients.

March 6, 2005

Preventing retained surgical items.

August 3, 2022

Missed opportunities to initiate endoscopic evaluation for colorectal cancer diagnosis.

November 18, 2009

Patient safety systems in the primary health care of diabetes—a story of missed opportunities?

November 17, 2010

Paramedics and the effects of shift work on sleep: a literature review.

February 29, 2012

Medical errors involving trainees: a study of closed malpractice claims from 5 insurers.

October 24, 2007

Reducing diagnostic errors through effective communication: harnessing the power of information technology.

April 23, 2008

Identifying diagnostic errors in primary care using an electronic screening algorithm.

February 21, 2007

A mixed method study of the merits of e-prescribing drug alerts in primary care.

April 30, 2008

Nurses' use of computerized clinical guidelines to improve patient safety in hospitals.

May 6, 2015

Extended work duration and the risk of self-reported percutaneous injuries in interns.

September 6, 2006

Ten years after the IOM report: engaging residents in quality and patient safety by creating a house staff quality council.

March 30, 2011

Medication errors in pediatric anesthesia: a report from the Wake Up Safe quality improvement initiative.

November 22, 2017

Success in hospital-acquired pressure ulcer prevention: a tale in two data sets.

December 12, 2018

The role of housestaff in implementing medication reconciliation on admission at an academic medical center.

June 16, 2010

Improving communication with primary care physicians at the time of hospital discharge.

February 8, 2017

Association between elements of electronic health record systems and the weekend effect in urgent general surgery.

April 12, 2017

The dichotomy of the application of a systems approach in UK healthcare the challenges and priorities for implementation.

May 3, 2017

Characteristics of healthcare organisations struggling to improve quality: results from a systematic review of qualitative studies.

September 5, 2018

Developing indicators of inpatient adverse drug events through nonlinear analysis using administrative data.

October 24, 2007

Risk assessment of the acute stroke diagnostic process using failure modes, effects, and criticality analysis.

March 1, 2023

Improving patient safety—five years after the IOM report.

March 6, 2005

High-alert medications in the pediatric intensive care unit.

January 7, 2009

On the prospects for a blame-free medical culture.

November 4, 2009

The costs of adverse drug events in hospitalized patients.

March 27, 2005

Understanding the healthcare workplace learning culture through safety and dignity narratives: a UK qualitative study of multiple stakeholders' perspectives.

June 12, 2019

Comparing catheter-associated urinary tract infection prevention programs between Veterans Affairs nursing homes and non–Veterans Affairs nursing homes.

April 5, 2017

Implementing an error disclosure coaching model: a multicenter case study.

February 22, 2017

Making electronic prescribing alerts more effective: scenario-based experimental study in junior doctors.

August 31, 2011

Building and sustaining a systemwide culture of safety.

December 14, 2005

More holes than cheese. What prevents the delivery of effective, high quality, and safe healthcare in England?

November 16, 2016

Achieving the Institute of Medicine's 6 aims for quality in the midst of the opioid crisis: considerations for the emergency department.

January 10, 2018

What US hospitals are doing to prevent common device-associated infections during the coronavirus disease 2019 (COVID-19) pandemic: results from a national survey in the United States.

June 21, 2023

Improving safety culture results in Rhode Island ICUs: lessons learned from the development of action-oriented plans.

November 2, 2011

Addressing dual patient and staff safety through a team-based standardized patient simulation for agitation management in the emergency department.

June 13, 2018

Increasing medication error reporting rates while reducing harm through simultaneous cultural and system-level interventions in an intensive care unit.

July 20, 2011

Hospital rules-based system: the next generation of medical informatics for patient safety.

April 15, 2005

Synergy for patient safety and quality: academic and service partnerships to promote effective nurse education and clinical practice.

February 15, 2012

Eight critical factors in creating and implementing a successful simulation program.

January 15, 2014

Patients' willingness and ability to identify and respond to errors in their personal health records: mixed methods analysis of cross-sectional survey data.

July 27, 2022

Disclosing errors to patients: perspectives of registered nurses.

January 14, 2009

Evaluation of the association between Hospital Survey on Patient Safety Culture (HSOPS) measures and catheter-associated infections: results of two national collaboratives.

June 22, 2016

Parents' perceptions of medical errors.

June 16, 2010

Evaluation of the association between Nursing Home Survey on Patient Safety culture (NHSOPS) measures and catheter-associated urinary tract infections: results of a national collaborative.

October 18, 2017

Risk-adjusted cumulative sum for early detection of hospitals with excess perioperative mortality.

December 13, 2023

Identification of in-hospital complications from claims data. Is it valid?

March 6, 2005

Strategies to identify patient risks of prescription opioid addiction when initiating opioids for pain: a systematic review.

June 19, 2019

From research to practice: factors affecting implementation of prospective targeted injury-detection systems.

June 8, 2011

The effect of a clinical decision support for pending laboratory results at emergency department discharge.

February 13, 2019

Self-reported adverse events in health care that cause harm: a population-based survey.

May 13, 2009

Interpreting and coding causal relationships for quality and safety using ICD-11.

February 28, 2024

Validation of a teamwork perceptions measure to increase patient safety.

August 27, 2014

Effect of computerized physician order entry and a team intervention on prevention of serious medication errors.

March 27, 2005

Artificial intelligence systems for complex decision-making in acute care medicine: a review.

March 13, 2019

Overrides of medication-related clinical decision support alerts in outpatients.

January 8, 2014

A program to prevent catheter-associated urinary tract infection in acute care.

June 8, 2016

Using a risk assessment approach to determine which factors influence whether partially bilingual physicians rely on their non-English language skills or call an interpreter.

August 22, 2012

Intervention to reduce transmission of resistant bacteria in intensive care.

February 1, 2012

Related Resources

Patient Safety Authority Annual Reports.

May 1, 2023

Long-term care healthcare-associated infections in 2021: an analysis of 17,971 reports.

July 13, 2022

Impact of full personal protective equipment on alertness of healthcare workers: a prospective study.

February 2, 2022

Patient safety in dermatology: a ten-year update.

June 23, 2021

Impact of COVID-19 on inpatient clinical emergencies: a single-center experience.

June 9, 2021

Clinical characteristics and short-term outcomes of acute kidney injury missed diagnosis in older patients with severe COVID-19 in intensive care unit.

May 19, 2021

TeamSTEPPS for the COVID-19 Crisis.

February 10, 2021

Health care workers in the midst of crisis.

February 10, 2021

Healthcare failure mode and effect analysis (HFMEA) as an effective mechanism in preventing infection caused by accompanying caregivers during COVID-19-experience of a city medical center in Taiwan.

January 27, 2021

The impact of COVID-19 response on central line associated bloodstream infections and blood culture contamination rates at a tertiary care center in greater Detroit area.

December 16, 2020

Impact of SARS-CoV-2 on hospital acquired infection rates in the United States: predictions and early results.

November 25, 2020

Assisting beginners in root cause analysis operations: analysis and recommendations regarding the spread of COVID-19 in nursing facilities for the elderly.

September 30, 2020

Nurses and doctors sick with COVID feel pressured to get back to work.

August 26, 2020

Personal protective equipment (PPE) for surgeons during COVID-19 pandemic: a systematic review of availability, usage, and rationing.

June 3, 2020

In-hospital mortality associated with the misdiagnosis or unidentified site of infection at admission.

July 31, 2019

Reducing three infections across cardiac surgery programs: a multisite cross-unit collaboration.

May 22, 2019

Prevalence, underlying causes, and preventability of sepsis-associated mortality in US acute care hospitals.

February 27, 2019

Clinical impact and economic burden of hospital-acquired conditions following common surgical procedures.

February 13, 2019

Infection prevention in long-term care: re-evaluating the system using a human factors engineering approach.

February 13, 2019

Learning from tragedy: the Julia Berg story.

December 12, 2018

Are teaching hospitals treated fairly in the Hospital-Acquired Condition Reduction Program?

December 12, 2018

Changes in prevalence of health care-associated infections in U.S. hospitals.

November 14, 2018

Potentially inappropriate opioid prescribing, overdose, and mortality in Massachusetts, 2011–2015.

October 3, 2018

Avoidable sepsis infections send thousands of seniors to gruesome deaths.

September 19, 2018

Antimicrobial Stewardship.

September 19, 2018

Hospital-Acquired Condition (HAC) Reduction Program.

September 5, 2018

Prejudice in perceptions of physicians?: The influence of race and gender on evaluations of medical errors.

August 8, 2018

Medication for opioid use disorder after nonfatal opioid overdose and association with mortality: a cohort study.

July 11, 2018

Taking the heat or taking the temperature? A qualitative study of a large-scale exercise in seeking to measure for improvement, not blame.

May 23, 2018

Focused ethnography of diagnosis in academic medical centers.

May 9, 2018

See More About The Topic

Hospitals

Physicians

Infectious Diseases

Nosocomial Infections

Active Errors

Identification and characterization of failures in infectious agent transmission precaution practices in hospitals: a qualitative study.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Identification and characterization of failures in infectious agent transmission precaution practices in hospitals: a qualitative study.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site