842 infection control & hospital epidemiology july 2018, vol. 39, no. 7


Campaign,” which emphasizes the use of 1 needle and 1 syringe for each patient and the correct usage of multidose (MDV) and single-dose (SDV) vials.1 The CDC also recom- mends implementing training programs to reinforce safe injection practices and monitoring adherence to the recommendations.1 The Institute of Medicine (IOM) promotes viewing safety


from a systems perspective11 and asserts that healthcare out- comes do not result from the action of a single individual but depend on the interaction of many factors, including envir- onment of practice, organizational culture and structure, and human factors.12 Focusing on just 1 of these factors does not necessarily produce the desired improvements in healthcare outcomes.13 The continued occurrence of unsafe medication- vial usage suggests that the knowledge of safe practices alone is not enough to ensure adherence.14,15 The Systems Engineering Initiative for Patient Safety (SEIPS) model, which emphasizes persons, organization, technologies and tools, tasks, and environment12 is one framework used to evaluate healthcare systems. Understanding the SEIPS barriers and facilitators that pre-


vent or assist safe injection practices can help guide clinical interventions to reduce disease risk exposure. In a recent study by Anderson et al,15 HCWs self-reported a high knowledge of injection safety and no barriers to safe usage of medication vials; however, observation data collected in the same study revealed significant nonadherence to safe usage of medication vials. In addition, 2 other studies that collected anonymous survey data from clinicians reported that reuse of syringes for multiple patients still occurs in practice.16,17 At the time of this project, few other published studies have described the extent of nonadherence to available injection safety standards, and no published studies have described contributing factors to these practices. The goal of this study is to identify barriers and facilitators to safe injection practices in the ambulatory setting to guide quality improvement interventions.


methods


An invitation for voluntary study participation was sent to the manager or director at clinic sites that were known to perform intramuscular, intradermal, intravenous, or intra-articular injections. Observations and interviews were conducted in person by investigators familiar with site-visit observation and standardized interviewing techniques. Clinics that accom- modate high volumes of patients, defined as 1 patient every 15–45 minutes, as well as those that provide urgent care or same-day services or perform invasive procedures, were given priority. Participating clinics were categorized by type and included adult primary care, pediatric primary care, family medicine, urgent care, medical specialty services, procedural centers, dialysis centers, and imaging departments. To main- tain confidentiality, the names of participating staff were not recorded.


Observations


The investigator observed the preparation and administration of 10 injections or all injections within 2 hours, whichever came first. We defined 1 injection as the administration of medication or contrast through 1 syringe to 1 patient. If the observed staff member also participated in the interview, observation was completed first. For each injection observed, the investigator recorded whether staff performed the elements of safe injection using a checklist of safe injection standards guided by the CDC, the National Institute for Occupational Safety and Health, and the American Nurses’ Association standards on safe injection and the prevention of needle stick injuries (Table 1).18–20 For all standards, the investigator recorded “yes” if the standard was performed or “no” if it was not performed (Table 1). The observer offered guidance to the staff at the time of observing a practice not meeting standards. Totals for each standard were calculated using Microsoft Excel. In some clin- ics, interviews were conducted even though no injections were observed.


Interviews


Semistructured interviews consisted of 5 open-ended ques- tions that addressed each of the SEIPS domains: persons, organization, technologies and tools, tasks, and environment (Table 2). Following observations, the investigator interviewed at least 1 staff member who performed injections at the clinic site and a supervisor. Interviews were digitally recorded and transcribed when possible. Information was transcribed, and data were entered into the QDA Miner Lite software program (Provalis Research, Montreal, Quebec, Canada) to assist with the coding of themes according to SEIPS domains of persons, organization, technologies and tools, tasks, and environment. Each coded segment was classified as a barrier or facilitator and whether it was reported by supervisory staff. It was then assigned a category and grouped according to common theme or multiple themes if applicable. The frequency of each theme and their attribution as a facilitator or barrier to injection safety were calculated (Figures 1 and 2). Finally, the observed data and interview data were compared to identify associations between the elements performed and the SEIPS themes reported (Table 1). This project was considered a quality improvement study and was exempt from review by our institutional review board.


results


Of the 32 clinics contacted between May and August 2017, 21 clinics participated in this study. Of the 11 nonparticipating clinics, the most common reasons for declining participation were (1) staff turnover issues, (2) giving injections so infre- quently that none would be observed, (3) providers giving the injections did not have time to accommodate the visit, or


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