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


of the reported barriers and facilitators across clinic types demonstrate that some measures intended to improve safety of practices (eg, separation of medication preparation and clean supplies frompatient care areas) can create challengingworkflows and result in (at aminimum) staff perceptions that the injections are less safe. An ideally designed system, environment, and work contextwould enable safe injections without hindering workflow. In this way, the human factors approach mirrors a widely


accepted hierarchy of public health interventions, in which a high likelihood of positive impact exists when the individual’s context can be modified so that default decisions align with healthy and desired actions (eg, those that promote injection safety) and when the effort level required by an individual (eg, to check a medication vial expiration date) is lowest.10 In contrast, education and training, which are often the focus of infection prevention interventions, are less likely to result in positive or sustained impact in the absence of other interven- tions that address broader systems issues.10–12 The human factors approach as applied for the purpose


of infection prevention and control has advantages and disadvantages (Table 1). The most compelling advantage is the potential to identify major underlying causes and contributors to a problem. Just as Leback et al discovered that feeling rushed might have a more powerful influence on practices than injec- tion safety knowledge, training, supplies or technology, there are opportunities to gain important insights into why lapses in other important infection prevention practices can occur, and how to intervene. This approach considers multiple broad outcomes simultaneously and assumes that staff engagement and job satisfaction are integrally linked to positive organiza- tional outcomes (ie, recognition and profitability) and health and safety outcomes such as healthcare-associated infections (HAIs).5 The idea that improvements in staff well-being can serve as a “rising tide” to positively affect other outcomes in healthcare has obvious merits. The human factors approach has 2 potential disadvantages:


its resource-intense nature and generalizability of evaluation findings and solutions. Detailed evaluations can be expensive


table 1. Human Factors Approach to Infection Prevention


Advantages ∙ Considers multiple, interrelated factors and outcomes, including staff well being


∙ Acknowledges complexity of healthcare systems and processes ∙ Identification of “upstream” causes and more sustainable solutions ∙ Demonstrated success in promoting safety in other industries ∙ Applicable to range of issues that might influence HAIs (eg, from availability of supply kits to how teams work and communicate, to cognitive load and interruptions) Disadvantages ∙ Potentially resource intensive ∙ Low generalizability of findings ∙ Availability of human factors expertise (and involvement during implementation and post-implementation phases)


∙ Assumes “persons” are primarily employees of the organization


and time-consuming, and ready solutions to certain issues, such as physical infrastructure, staffing, or workload, might not exist. Human factors experts with experience in healthcare are not available to every healthcare system,11 and they might not be available at all to freestanding clinics that lack hospital affiliation. Because human factors assesses the interactions among humans, technology, and environments within systems, these factors can all differ in each clinic, hospital unit,


been employed in the field of infection prevention. Checklists, implementation bundles, and other tools have been famously adopted and incorporated as staples of device-associated infection prevention.13–15 Communication tools, strategies and technologies are also in use to improve the transfer of information that is essential to infection control or antimicrobial stewardship.16–18 Usability testing of the human-machine interaction is conducted by manufacturers of reprocessing machines or environmental disinfection devices. In addition, efforts exist to integrate infection prevention considerations into healthcare facility design, albeit largely focused on hospital settings.19 Collaborations between healthcare epidemiologists and human factors engineers, and inclusion of human factors experts in infection prevention and control efforts, appears to be a more recent phenomenon. Rock et al20 utilized the SEIPS model and conducted a human factors evaluation to discern opportunities to improve environmental cleaning and disinfection of patient rooms. The evaluators identified multiple strategies in the domains of persons, tasks, organization, environment, and tools and technology that could result in desired improvements to patient room disinfection. The human factors and systems engineering approach has also been utilized to conduct several other evaluations of barriers and facilitators to infection pre- vention practices (eg, hand antisepsis and C. difficile preven- tion) and clinical guideline adherence.21–23 In these examples, human factors has advanced our knowledge of why and how systems, and the humans operating within those systems, fail to prevent HAIs. What is needed now are additional demon- strations that such findings can directly inform strategies and interventions that positively impact primary outcomes, such as HAIs or antimicrobial resistance. Adherence to standard practices and interventions that have


or other local healthcare setting, the generalizability of research findings is potentially undermined. Despite this, Leback et al identified common themes across different clinic types, and it is possible that some settings (eg, outpatient dialysis clinics with shared corporate ownership) might have many more similarities than differences in factors such as tasks, environ- ments, technology, and organization. Strategies based upon human factors principles have long


been shown to prevent infections in healthcare settings remains a critical challenge. The work done by Leback et al extends the science of human factors and systems engineering to outpatient settings, where adherence gaps may be greatest, and it highlights the promising nature of these approaches for improving patient care and outcomes. Ultimately, the value of


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