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


Human Factors and Systems Engineering: The Future of Infection Prevention?


Priti R. Patel, MD, MPH, Alexander J. Kallen, MD, MPH


(See article by Leback et al, pages 841-848.) Human factors is a discipline that utilizes the “under-


standing of interactions among humans and other elements of a system” and methods and design principles to “optimize the human well-being and overall system performance.”1 The field traces its origins to the study and design of human operator use of military systems and equipment.2 Human factors approa- ches to certain subtopics such as accidents, human error, and warning systems have been used to improve safety in industries including aviation, aerospace, transportation, and mining. The same principles and methods can also be applied to improving safety in healthcare systems, particularly as new technologies are incorporated into healthcare delivery, in the form of medical and surgical devices, health informatics, electronic medical record clinical decision supports, and health monitoring devices. In this issue, Leback et al3 describe results of injection-


safety–focused observations and interviews conducted in a range of outpatient clinical settings within a single health system. Challenges to basic injection safety standards (eg, syringe reuse for >1 patient) persist in many healthcare settings,3,4 necessitating a thorough understanding of barriers to safe practices and innovative approaches to overcome such barriers, especially in outpatient clinics. Clinics in this study included adult and pediatric primary-care clinics, dialysis centers, urgent care clinics, imaging clinics, and outpatient procedure clinics. Observations of injection practices were conducted, and interviews of staff were also performed to understand barriers and facilitators to injection safety in the clinics. The authors utilized a human factors approach to evaluate interview responses and connected themes to the observation data. The Systems Engineering Initiative for Patient Safety (SEIPS)5 framework was used to design inter- view questions and classify barriers and facilitators into the SEIPS categories of: workflow, persons, organization, envir- onment, and tools and technology. This study contributes several pertinent findings. First,


generally good adherence to recommended safe injection practices was observed across clinics, including proper use of single dose vials (ie, 1-time use for 1 patient only). However,


opportunities for improvement were identified, such as keep- ing multidose vials out of patient care areas and cleansing septa of vials prior to accessing. Second, according to the authors, the observations conducted in the study uncovered a greater number of gaps compared to routine infection prevention site visits of these same clinics that have relied upon self-reports of practice. This finding reinforces the importance of direct observations of practice as part of on-site assessments, which is a component of the CDC Guide to Infection Prevention in Outpatient Settings6 and is essential to any evaluation of infection control practice. Third, and perhaps most enlightening, is the analysis of the interview responses. For most SEIPS categories, roughly half of responses were coded as barriers. The exception was the tools and technologies category, for which only 27% of responses were barriers. All barriers were specifically reported as ones that make it difficult to give injections safely. The most frequently reported barrier, in any category, to giving safe injections was feeling rushed or high patient turnover. While perhaps not surprising, it should be alarming that staff across different clinic types reported this pervasive issue that has such potential to cause medical errors. Important barriers related to the environment were small patient-care areas and medication rooms, and an excessive distance between these 2 areas. Notable facilitators were the availability of injection supplies in work areas, and a commonly reported facilitator in the cate- gory of workflow was preparing medications in advance. The latter is a logical strategy to avoid errors when feeling rushed, yet it is at odds with recommendations to prepare medications as close in time as possible to their administration. This is particularly true if staff are engaging in batch preparation of medications for multiple patients, a practice that has con- tributed to outbreaks of infection.7,8 The Institute for Safe Medication Practices (ISMP) has recommended avoiding the need for vial manipulation and syringe preparation in the clinic setting through the use of manufacturer-prefilled or pharmacy-prepared prefilled syringes for i.v. push medications and flush.9 When available, the use of “ready-to-administer” medications can save time, improve workflow, and reduce opportunities for errors and contamination. In this study, many


Affiliations: Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia.


© 2018 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2018/3907-0012. DOI: 10.1017/ice.2018.122 Received April 24, 2018; accepted April 28, 2018


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