injection safety 847
served as reminders for skills and safety concerns and provided assurance that staff adhered to safe injection practices. Both managers and staff reported that a culture of teamwork and accessible resources were important to injection safety.
Tools and Technology
Of the 198 segments coded to tools and technology, only 54 (27%) were classified as barriers. The most frequently reported facilitator was the availability of supplies near the work area (Figure 2). Although most participants reported the availability of safety needles and other types of safety devices as a facilitator, some reported safety needles as barriers because they obstructed visualization of the injection site or required the user to push up the shield over the needle with one or both hands. Characteristics of types of syringe were also important to participants. Another frequently reported facilitator was access to an electronicmedical record (EMR) to assist with preparing medication and access to other online resources. Finally, although patient movement was the most frequently reported barrier in the “Persons” section of the study, tools used for needle pain management were reported less frequently as facilitators.
discussion
Concurrent use of observations followed by interviews allowed investigators to better identify gaps in injection safety practice. Interestingly, the safe practice elements that investigators observed were not frequently discussed in the interviews. Preference for using SDVs over MDVs was reported rarely in interviews, despite the recommended practices involving MDV use being suboptimal in observations. Thus, the self- reported data may not sufficiently gauge actual practice in the clinics. This finding is consistent with the study by Anderson et al, 11 which highlighted deficits in safe practice despite survey responses reporting no barriers. Instead of directly discussing safe injection practices, many
interview participants focused on elements that may indirectly impact the medication administration process or the overall daily clinic workflow. This type of response is supported by the most frequently reported barrier, the perception of being rushed. The interviews revealed that infection control aspects of safe injection practices are perceived to be closely connected with other clinic processes. Therefore, addressing practice concerns from only an infection control perspective may not achieve improved adherence to safe injection practices. The strengths of this study include that observations and
interviews were performed at a variety of outpatient settings offering different medical services as well as settings that give injections at different frequencies (Table 1). Semistructured interviews allowed investigators to gather diverse responses from both clinical staff directly involved in patient care as well as par- ticipants in managerial or supervisory roles. Observations also captured a wide variety of patient care staff, including medical assistants, licensed practical nurses, and physicians.
This study has several limitations. The possibility of reporting bias in interviews could not be excluded due to the inherent pressure to give a socially desirable response. Staff may have known the correct practice for injections but have been hesitant to report factors in which their practice deviates from the accepted one for fear of penalty. The greater number of reported facilitators over barriers may indicate the presence of this bias. Participants may have changed injection practices due to the presence of the observer. Because of time limitations in the study, investigators were only able to observe a small number of injections given in a period, and sometimes inves- tigators observed the same staff for multiple injections. Thus, it is impossible to generalize results to all injections performed across all clinics. Finally, because of the limitations in the scope of the study, only a small number of the total reported barriers and facilitators could be discussed here. Given the limitations of self-reporting, organizations may incorporate this model of observation to identify areas of nonadherence to practice standards and policies. The infection prevention department at the organization in this study rou- tinely performs site visits to assess adherence to regulatory standards of safe injection, much like the elements assessed in this study. Most of the information gathered during these site visits is obtained through the self-report from the clinic manager. Because the observations of this study revealed more deficits in safe practice than the site visits reports, the study suggests that it may be necessary to monitor for adherence of regulatory standards with additional observations. Future studies should aim to collect a larger amount of observation data from different staff members across the clinics. Inadequate staffing and staff unfamiliar with the clinic workflow were identified as barriers; thus, clinics that declined participation in the study due to staffing or training issues may have more unrecognized safe injection performance chal- lenges. Because of the design, this study could not explore causative factors of nonadherence to safe injection practices. Additional studies on the effect of interventions focusing on the identified barriers and facilitators are needed. In conclusion, perceived barriers and facilitators to
infection control elements of injection safety are interconnected with the SEIPS elements of persons, organizations, technologies, tasks, and environment affecting injection administration and clinic processes. Frequently identified barriers included patient reactions during injection administration and challenging staff workflows. Frequently identified facilitators were supplies avail- ability and appropriate safety
devices.Direct observationsmay not align with self-reported data and may be necessary to accurately assess adherence to injection best practices.
acknowledgments
The authors would like to acknowledge clinic mangers and staff participating in the observations and interviews as well as Julia Jensen, University of Wisconsin School of Medicine and Public Health, MPH 2018 Candidate, for her work reviewing the interview transcripts, and Mary Hitchcock,
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