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


figure 2. Frequency (%) of reported facilitators, arranged by System Engineering Initiative for Patient Safety (SEIPS) category.


the checklist standards. For instance, none of the participants noted barriers to cleansing the rubber hub of the vial prior to accessing, despite that element only being followed 86% of the time. The only standards explicitly mentioned in interview responses were the availability and correct use of safety devices and the availability of needleless devices for preparation of injectables. No pattern was noted between responses and type of clinic or between staff within clinics. Themes indirectly relating to checklist standards along with SEIPS categories are reported in Table 1 with the frequencies of adherence by clinic type.


Workflow


A wide variety of responses were recorded for the workflow category, reflecting the diversity of practice across participating clinics. In total, 72 different themes were assigned to 154 coded segments, 87 (55%) of which were described as barriers. The most frequently described barrier was the perception of feeling rushed and a high patient turnover (Figure 1). One participant commented that being in a hurry increases the risk for missing steps in the injection process. For reported facilitators, themes that included planning ahead for the injections emerged. Some technical aspects of injection administration were also noted to be facilitators (Figure 2).


Persons


Of the 202 segments coded to persons, 101 (50%) were described as barriers. The most frequently described barrier


theme was patient movement during the injection (Figure 1), such as jumping or attempting to swat the hands of the HCW. One participant described having to hold a child during an immunization due to concerns of the child jumping and causing a needlestick injury. In pediatric populations, HCWs reported this type of patient reaction most often. For facil- itators, a primary theme involved attempts to ameliorate a negative patient reaction. However, facilitators most fre- quently described were positive characteristics of staff giving the injection and available resources (Figure 2).


Environment


Of the 129 segments coded to environment, 51 (40%) were considered barriers to safe injection practice, including lack of space, smaller patient care areas, and limited storage supply space. Themost commonfacilitator reported by both staff and managers was having injection supplies near work areas. Other common themes characterized the room in which medications are prepared and the availability of adjustable equipment (Figure 2).


Organization


Of the 136 segments coded to organization, 67 (49%) were clas- sified as barriers. Most of the barrier themes involved inadequate staffing and training (Figure 1). Financial barriers were reported exclusively by managers. Managers were more likely than staff members to report annual skill competencies as helpful (Figure 2). One manager explained that regular competencies


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