Hostname: page-component-f554764f5-8cg97 Total loading time: 0 Render date: 2025-04-15T00:43:31.676Z Has data issue: false hasContentIssue false
  • English
  • Français

Human factors–based risk analysis to improve the safety of doffing enhanced personal protective equipment

Published online by Cambridge University Press:  06 December 2018

Ayse P. Gurses Open the ORCID record for Ayse P. Gurses [Opens in a new window] ,
Aaron S. Dietz ,
Elaine Nowakowski ,
Jennifer Andonian ,
Maggie Schiffhauer ,
Carrie Billman ,
Anya M. Abashian ,
Polly Trexler ,
Patience Osei  and
Lauren E. Benishek
...Show all authors
Ayse P. Gurses*
Affiliation:
Armstrong Institute Center for Health Care Human Factors, The Johns Hopkins University School of Medicine, Baltimore, Maryland Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
Aaron S. Dietz
Affiliation:
Armstrong Institute Center for Health Care Human Factors, The Johns Hopkins University School of Medicine, Baltimore, Maryland Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
Elaine Nowakowski
Affiliation:
Department of Hospital Epidemiology and Infection Control, Johns Hopkins Hospital, Baltimore, Maryland
Jennifer Andonian
Affiliation:
Department of Hospital Epidemiology and Infection Control, Johns Hopkins Hospital, Baltimore, Maryland
Maggie Schiffhauer
Affiliation:
Department of Hospital Epidemiology and Infection Control, Johns Hopkins Hospital, Baltimore, Maryland
Carrie Billman
Affiliation:
Department of Hospital Epidemiology and Infection Control, Johns Hopkins Hospital, Baltimore, Maryland
Anya M. Abashian
Affiliation:
Department of Hospital Epidemiology and Infection Control, Johns Hopkins Hospital, Baltimore, Maryland
Polly Trexler
Affiliation:
Department of Hospital Epidemiology and Infection Control, Johns Hopkins Hospital, Baltimore, Maryland
Patience Osei
Affiliation:
Armstrong Institute Center for Health Care Human Factors, The Johns Hopkins University School of Medicine, Baltimore, Maryland
Lauren E. Benishek
Affiliation:
Armstrong Institute Center for Health Care Human Factors, The Johns Hopkins University School of Medicine, Baltimore, Maryland Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
Anping Xie
Affiliation:
Armstrong Institute Center for Health Care Human Factors, The Johns Hopkins University School of Medicine, Baltimore, Maryland Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
Peter Pronovost
Affiliation:
Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
Michael A. Rosen
Affiliation:
Armstrong Institute Center for Health Care Human Factors, The Johns Hopkins University School of Medicine, Baltimore, Maryland Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
Lisa L. Maragakis
Affiliation:
Department of Hospital Epidemiology and Infection Control, Johns Hopkins Hospital, Baltimore, Maryland Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
for the CDC Prevention Epicenter Program
Affiliation:
Armstrong Institute Center for Health Care Human Factors, The Johns Hopkins University School of Medicine, Baltimore, Maryland Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland Department of Hospital Epidemiology and Infection Control, Johns Hopkins Hospital, Baltimore, Maryland Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
*
Author for correspondence: Ayse P. Gurses, Armstrong Institute Center for Health Care Human Factors, Johns Hopkins University School of Medicine, 750 East Pratt Street, 15th Floor, Baltimore, MD 21202. E-mail: [email protected]
Get access Rights & Permissions [Opens in a new window]

Abstract

Objective

To systematically assess enhanced personal protective equipment (PPE) doffing safety risks.

Design

We employed a 3-part approach to this study: (1) hierarchical task analysis (HTA) of the PPE doffing process; (2) human factors-informed failure modes and effects analysis (FMEA); and (3) focus group sessions with a convenience sample of infection prevention (IP) subject matter experts.

Setting

A large academic US hospital with a regional Special Pathogens Treatment Center and enhanced PPE doffing protocol experience.

Participants

Eight IP experts.

Methods

The HTA was conducted jointly by 2 human-factors experts based on the Centers for Disease Control and Prevention PPE guidelines. The findings were used as a guide in 7 focus group sessions with IP experts to assess PPE doffing safety risks. For each HTA task step, IP experts identified failure mode(s), assigned priority risk scores, identified contributing factors and potential consequences, and identified potential risk mitigation strategies. Data were recorded in a tabular format during the sessions.

Results

Of 103 identified failure modes, the highest priority scores were associated with team members moving between clean and contaminated areas, glove removal, apron removal, and self-inspection while preparing to doff. Contributing factors related to the individual (eg, technical/ teamwork competency), task (eg, undetected PPE contamination), tools/technology (eg, PPE design characteristics), environment (eg, inadequate space), and organizational aspects (eg, training) were identified. Participants identified 86 types of risk mitigation strategies targeting the failure modes.

Conclusions

Despite detailed guidelines, our study revealed 103 enhanced PPE doffing failure modes. Analysis of the failure modes suggests potential mitigation strategies to decrease self-contamination risk during enhanced PPE doffing.

Type
Original Article
Information
Infection Control & Hospital Epidemiology , Volume 40 , Issue 2 , February 2019 , pp. 178 - 186
Copyright
© 2018 by The Society for Healthcare Epidemiology of America. All rights reserved. 

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

Article purchase

Temporarily unavailable

Footnotes

Cite this article: Gurses AP. (2019). Human factors–based risk analysis to improve the safety of doffing enhanced personal protective equipment. Infection Control & Hospital Epidemiology 2019, 40, 178–186. doi: 10.1017/ice.2018.292

References

1. 2014 Ebola outbreak in West Africa—case counts. Center for Disease Control and Prevention website. https://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/case-counts.html. Published 2016. Accessed October 25, 2018.Google Scholar
2. Health worker Ebola infections in Guinea, Liberia and Sierra Leone: a preliminary report. World Health Organization website. http://www.who.int/hrh/documents/21may2015_web_final.pdf. Published 2015. Accessed October 25, 2018.Google Scholar
3. Personal Protective Equipment (PPE). Centers for Disease Control and Prevention website. https://www.cdc.gov/vhf/ebola/healthcare-us/ppe/index.html. Published 2016. Accessed October 25, 2018.Google Scholar
4. Gurses, A, Seidl, K, Vaidya, V, et al. Systems ambiguity and guideline compliance: a qualitative study of how intensive care units follow evidence-based guidelines to reduce healthcare-associated infections. Qual Saf Health Care 2008;17:351–359.Google Scholar
5. Gurses, AP, Marsteller, JA, Ozok, AA, Xiao, Y, Owens, S, Pronovost, PJ. Using an interdisciplinary approach to identify factors that affect clinicians’ compliance with evidence-based guidelines. Crit Care Med 2010;38:S282–S291.Google Scholar
6. Definition and domains of ergonomics. International Ergonomics Association website. https://www.iea.cc/whats/. Published 2018. Accessed October 25, 2018.Google Scholar
7. Sanders, M, McCormick, E. Human error, accidents, and safety. Human Factors in Engineering and Design . Berkshire, UK: McGraw Hill; 1993.Google Scholar
8. Sax, H, Clack, L. Mental models: a basic concept for human factors design in infection prevention. J Hosp Infect 2015;89:335–339.Google Scholar
9. Anderson, J, Gosbee, LL, Bessesen, M, Williams, L. Using human factors engineering to improve the effectiveness of infection prevention and control. Crit Care Med 2010;38:S269–S281.Google Scholar
10. Yanke, E, Zellmer, C, Van Hoof, S, Moriarty, H, Carayon, P, Safdar, N. Understanding the current state of infection prevention to prevent Clostridium difficile infection: a human factors and systems engineering approach. Am J Infect Control 2015;43:241–247.Google Scholar
11. Yanke, E, Carayon, P, Safdar, N. Translating evidence into practice using a systems engineering framework for infection prevention. Infect Control Hosp Epidemiol 2014;35:1176–1182.Google Scholar
12. Gurses, AP, Rosen, MA, Pronovost, PJ. Improving guideline compliance and healthcare safety using human factors engineering: the case of Ebola. J Patient Saf Risk Manag 2018;23(3):93–95.Google Scholar
13. DeRosier, J, Stalhandske, E, Bagian, JP, Nudell, T. Using health care failure mode and effect analysis: the VA National Center for Patient Safety’s prospective risk analysis system. Joint Commission J Qual Improv 2002;28:248–267.Google Scholar
14. Rosen, M, Sampson, J, Jackson, E Jr, et al. Failure mode and effects analysis of the universal anaesthesia machine in two tertiary care hospitals in Sierra Leone. Brit J Anaesth 2014;113:410–415.Google Scholar
15. Davis, S, Riley, W, Gurses, AP, Miller, K, Hansen, H. Failure modes and effects analysis based on in situ simulations: a methodology to improve understanding of risks and failures. In: Henriksen K, Battles JB, Keyes MA, Grady ML, editors. SourceAdvances in Patient Safety: New Directions and Alternative Approaches, vol. 3. Rockville, MD: Agency for Healthcare Research and Quality; 2008.Google Scholar
16. Wetterneck, TB, Skibinski, KA, Roberts, TL, et al. Using failure mode and effects analysis to plan implementation of smart iv pump technology. Am J Health System Pharm 2006;63:1528–1538.Google Scholar
17. Wetterneck, TB, Hundt, AS, Carayon, P. FMEA team performance in health care: A qualitative analysis of team member perceptions. Journal of patient safety. 2009 Jun 1;5(2):102–108.Google Scholar
18. Faye, H, Rivera-Rodriguez, AJ, Karsh, B-T, Hundt, AS, Baker, C, Carayon, P. Involving intensive care unit nurses in a proactive risk assessment of the medication management process. Joint Comm J Qual Patient Saf 2010;36:376–AP371.Google Scholar
19. Carayon, P, Hundt, AS, Karsh, B, et al. Work system design for patient safety: the SEIPS model. Qual Saf Health Care 2006;15 Suppl 1:i50–i58.Google Scholar
20. Keller, SC, Tamma, PD, Cosgrove, SE, et al. Ambulatory antibiotic stewardship through a human factors engineering approach: a systematic review. J Am Board Fam Med 2018;31:417–430.Google Scholar
21. Katz, MJ, Gurses, AP, Tamma, PD, Cosgrove, SE, Miller, MA, Jump, RL. Implementing antimicrobial stewardship in long-term care settings: an integrative review using a human factors approach. Clin Infect Dis 2017;65:1943–1951.Google Scholar
22. Rock, C, Cosgrove, SE, Keller, SC, et al. Using a human factors engineering approach to improve patient room cleaning and disinfection. Infect Control Hosp Epidemiol 2016;37:1502–1506.Google Scholar
23. Xie, A, Rock, C, Hsu, YJ, Osei, P, Andonian, J, Scheeler, V, Keller, SC, Cosgrove, SE, Gurses, AP. Improving Daily Patient Room Cleaning: An Observational Study Using a Human Factors and Systems Engineering Approach. IISE Transactions on Occupational Ergonomics and Human Factors. 2018 Sep;11:1–4.Google Scholar
24. Lane, R, Stanton, NA, Harrison, D. Applying hierarchical task analysis to medication administration errors. Appl Ergonom 2006;37:669–679.Google Scholar
25. Stanton, NA, Salmon, PM, Rafferty, LA, Walker, GH, Baber, C, Jenkins, DP. Human Factors Methods: A Practical Guide for Engineering and Design. Boca Raton, FL: CRC Press; 2017.Google Scholar
26. Doffing PPE: Prepare to Doff Your PPE. Center for Disease Control and Prevention website. https://www.cdc.gov/vhf/ebola/hcp/ppe-training/PAPRRespirator_Gown/doffing_01.html. Published 2014. Accessed October 25, 2018.Google Scholar
27. Department of Defense Patient Safety Center. Failure Mode and Effects Analysis (FMEA): An Advisor’s Guide. Silver Spring, MD: US DOD; 2004.Google Scholar
28. King, HB, Battles, J, Baker, DP, et al. TeamSTEPPS: team strategies and tools to enhance performance and patient safety. In: Henriksen K, Battles JB, Keyes MA, Grady ML, editors. SourceAdvances in Patient Safety: New Directions and Alternative Approaches, vol. 3. Rockville, MD: Agency for Healthcare Research and Quality; 2008.Google Scholar
29. Dietz, AS, Driskell, JE, Sierra, MJ, Weaver, SJ, Driskell, T, Salas, E. Teamwork under Stress. In: Salas E, Rico R, Passmore J (editors). The Wiley Blackwell Handbook of the Psychology of Team Working and Collaborative Processes. Hoboken, NJ: Wiley-Blackwell; 2017:297–315.Google Scholar
30. Driskell, JE, Salas, E. Stress and Human Performance. New York: Psychology Press; 2013.Google Scholar
31. Trinkoff, AM, Johantgen, M, Storr, CL, Gurses, AP, Liang, Y, Han, K. Nurses’ work schedule characteristics, nurse staffing, and patient mortality. Nurs Res 2011;60:1–8.Google Scholar
32. Driskell, JE, Salas, E, Johnston, JH, Wollert, TN. Stress exposure training: an event-based approach. In: Szalma JL, Hancock PA (editors). Performance Under Stress. Hoboken, NJ: CRC Press; 2008:271–286.Google Scholar
33. Smith, EM, Ford, JK, Kozlowski, S. Building adaptive expertise: implications for training design. In: Quiñones MA, Ehrenstein A (editors). Training for a Rapidly Changing Workplace: Applications of Psychological Research. Washington, DC: APA Books; 1997:89–118.Google Scholar
34. Keith, N, Frese, M. Effectiveness of error management training: a meta-analysis. Journal of Applied Psychology. 2008 Jan;93(1):59.Google Scholar
35. Salas, E, DiazGranados, D, Klein, C, et al. Does team training improve team performance? A meta-analysis. Human Factors. 2008;50:903–933.Google Scholar
36. Hughes, AM, Gregory, ME, Joseph, DL, et al. Saving lives: a meta-analysis of team training in healthcare. J Appl Psychol 2016;101:1266–1304.Google Scholar
37. Dietz, AS, Pronovost, PJ, Benson, KN, et al. A systematic review of behavioural marker systems in healthcare: What do we know about their attributes, validity and application? BMJ Qual Saf 2014;23:1031–1039.Google Scholar
38. Rosen, MA, Dietz, AS. Team Performance Measurement. In: Salas E, Rico R, Passmore J (editors). The Wiley Blackwell Handbook of the Psychology of Team Working and Collaborative Processes. Hoboken, NJ: Wiley-Blackwell; 2017:479–502.Google Scholar
39. Guidance on personal protective equipment (PPE) to be used by healthcare workers during management of patients with confirmed Ebola or persons under investigation (PUIs) for Ebola who are clinically unstable or have bleeding, vomiting, or diarrhea in US hospitals, including procedures for donning and doffing PPE. Centers for Disease Control and Prevention website. https://www.cdc.gov/vhf/ebola/healthcare-us/ppe/guidance.html. Published 2015. Accessed October 25, 2018.Google Scholar
40. Picano, JJ, Williams, TJ, Roland, RR. Assessment and selection of high-risk operational personnel. In: Kennedy CH, Zillmer EA (editors). Military Psychology: Clinical and Operational Applications. New York: Guilford Press; 2006:353–370.Google Scholar
Supplementary material: File

Gurses et al. supplementary material

Appendix 1

Download Gurses et al. supplementary material(File)
File 77.5 KB
Supplementary material: File

Gurses et al. supplementary material

Appendix 2

Download Gurses et al. supplementary material(File)
File 77.5 KB
Supplementary material: File

Gurses et al. supplementary material

Appendix 3

Download Gurses et al. supplementary material(File)
File 22.5 KB