Infection Control & Hospital Epidemiology (2019), 40, 178–186 doi:10.1017/ice.2018.292
Original Article
Human factors–based risk analysis to improve the safety of doffing enhanced personal protective equipment
Ayse P. Gurses PhD, MS, MPH1,2, Aaron S. Dietz PhD1,2, Elaine Nowakowski3, Jennifer Andonian MPH, CIC3, Maggie Schiffhauer MHS, CIC3, Carrie Billman RN, BSN, CIC3, Anya M. Abashian MPH, CIC3, Polly Trexler MS, CIC3, Patience Osei MSE1, Lauren E. Benishek PhD1,2, Anping Xie PhD1,2, Peter Pronovost MD, PhD2,
Michael A. Rosen PhD1,2 and Lisa L. Maragakis MD, MPH3,4 for the CDC Prevention Epicenter Program 1Armstrong Institute Center for Health Care Human Factors, The Johns Hopkins University School of Medicine, Baltimore, Maryland, 2Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, 3Department of Hospital Epidemiology and Infection Control, Johns Hopkins Hospital, Baltimore, Maryland and 4Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
Abstract
Objective: To systematically assess enhanced personal protective equipment (PPE) doffing safety risks. Design: We employed a 3-part approach to this study: (1) hierarchical task analysis (HTA) of the PPE doffing process; (2) human factors- informed failure modes and effects analysis (FMEA); and (3) focus group sessions with a convenience sample of infection prevention (IP) subject matter experts. Setting: A large academic US hospital with a regional Special Pathogens Treatment Center and enhanced PPE doffing protocol experience. Participants: Eight IP experts. Methods: The HTA was conducted jointly by 2 human-factors experts based on the Centers for Disease Control and Prevention PPE guidelines. The findings were used as a guide in 7 focus group sessions with IP experts to assess PPE doffing safety risks. For each HTA task step, IP experts identified failure mode(s), assigned priority risk scores, identified contributing factors and potential consequences, and identified potential risk mitigation strategies. Data were recorded in a tabular format during the sessions. Results: Of 103 identified failure modes, the highest priority scores were associated with team members moving between clean and contaminated areas, glove removal, apron removal, and self-inspection while preparing to doff. Contributing factors related to the individual (eg, technical/ teamwork competency), task (eg, undetected PPE contamination), tools/technology (eg, PPE design characteristics), environment (eg, inadequate space), and organizational aspects (eg, training) were identified. Participants identified 86 types of risk mitigation strategies targeting the failure modes. Conclusions: Despite detailed guidelines, our study revealed 103 enhanced PPE doffing failure modes. Analysis of the failure modes suggests potential mitigation strategies to decrease self-contamination risk during enhanced PPE doffing.
(Received 8 January 2018; accepted 19 October 2018; electronically published 6 December 2018)
The 2014 Ebola virus disease (EVD) outbreak was the largest in history, claiming more than 10,000 lives.1 More than 600 healthcare workers (HCWs) died as a result of contracting EVD while caring for patients.2 Self-contamination while doffing per- sonal protective equipment (PPE) likely accounts for some of the HCW risk. In guidance to reduce this risk, the Centers for Disease Control and Prevention (CDC) recommends specific PPE com- ponents, steps for safe removal, and 2 new roles to assist the HCW.3 The ‘doffing team’ consists of the HCW, a trained observer (TO) to verbalize instructions and monitor safety of the
Author for correspondence: Ayse P. Gurses, Armstrong Institute Center for Health
Care Human Factors, Johns Hopkins University School of Medicine, 750 East Pratt Street, 15th Floor, Baltimore, MD 21202. E-mail:
agurses1@jhmi.edu
Cite this article: Gurses AP, et al. (2019). Human factors–based risk analysis to
improve the safety of doffing enhanced personal protective equipment. Infection Control & Hospital Epidemiology 2019, 40, 178–186. doi: 10.1017/ice.2018.292
© 2018 by The Society for Healthcare Epidemiology of America. All rights reserved.
practices or protocols.4,5 To protect HCWs, a better under- standing is needed of how self-contamination occurs and specific strategies that can be employed to mitigate risk. A human factors (HF) approach provides a useful framework to identify, analyze, and mitigate safety risks during PPE doffing. Human factors (HF) is a scientific discipline concerned with understanding interactions among humans and other system elements, and the profession that applies theory, principles, data, and methods to optimize human well-being and overall system performance.6 Human factors experts complete advanced training in engineering or psychology.7 Human factors principles and methods are useful to improve safety and infection prevention (IP) practices.4,5,8–12
doffing procedure, and a doffing assistant (DA) to help the HCW remove PPE components. Guidelines alone do not guarantee consistent adherence to best
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