Infection Control & Hospital Epidemiology
Table 3. Failure Modes with the Top 5 Risk Priority Number (RPN) Values Step
General/Applicable to all steps
183
Failure Mode
Assistant walks back and forth between dirty and clean areas
Severity Probability Detectability RPN 910
7 630
Contributing factors Person - TO inexperience; TO failure understand risk; lack of spatial awareness; distraction/attentional narrowing Organization - Organization does not provide training in the understanding of germ theory (and viruses/bacteria) and competency in disinfection/identifying and assessing risks Environment - No clear designation between clean and warm areas. Task - TO is focusing on multiple things simultaneously; ambiguity of whether the TO should always stay on the clean side Potential consequences 1. TO contaminates ‘clean’ area of doffing room 2. Others who pass through clean area become contaminated and do not know it (eg, carry it out of hall) Potential solutions for risk mitigation • Provide visual indication of contamination vs contamination free areas of doffing room • Provide education/ training in the understanding of germ theory (and viruses/bacteria) and competency in disinfection/identifying and assessing risks • Training should involve spatial orientation awareness between team members, environment, and equipment in relation to team-member body movements • Team members should utilize assertiveness techniques and speak up if they are unsure or uncomfortable • Ensure there is both a TO and assistant to facilitate the doffing process for the HCW; 1 person providing assistance alone will consistently cross into both clean/contaminated zones
3.1 Examine outer gloves for contamination Assistant/ TO do not identify all contamination 7 6 9
Contributing factors Person - False sense of security due to previous hand hygiene; false sense of security due to PPE being outer layer; vigilance decrement; TO/DA not comfortable to speak up; DA uncomfortable being too close to HCW Organization - Inadequate training for HCW and TO/DA on identifying contamination Environment - Physical distance between DA/TO and HCW Potential consequences 1. Further contamination by not identifying 2. Risk contaminating otherwise uncontaminated people or equipment Potential solutions for risk mitigation • Training for contamination identification • Education on contamination and assessing risks (why it is important and why it varies) • Utilize appropriate assertiveness techniques to speak up when concerned for contamination
1.1 Prepare to doff and inspect PPE
HCW does not complete full self-inspection prior to entering doffing room
76 8 366
Contributing factors Person - Inherent field of view limitations (ie, unable to see entire body without assistance); physical and mental fatigue; anxious reaction to potential breach; HCW did not communicate to TO that they are ready to leave the room and have completed self-inspection Tools/Technology – Folds in PPE Environmental – No mirror to see/help with inspection Task - Ambiguity on what exactly to assess/inspect; combative patient; only 1 HCW in room Potential consequences 1. HCW leaves patient room before they should 2. HCW unaware of contamination 3. HCW unaware of breach 4. HCW contaminated environment 5. HCW contaminates team member(s) Potential solutions for risk mitigation • Engage the TO earlier that HCW has completed pt. care and prepared to doff • If other HCW is in the room, have them assist • Provide HCWs with multiple body length mirrors in patient room • TO should utilize poly com if possible to always be able to communicate with and see (if possible) HCW
3.3 Disinfect outer gloves by rubbing top/bottom of both hands and in between fingers and thumbs
HCW does not thoroughly disinfect all surfaces 8 6
Contributing factors Person - Complacency of doffing team to ensure this is done effectively at all doffing stages; TO/DA not empowered to speak up; slip lapse Tools/Technology - Color of gloves can make it difficult to see; not enough ABHR Organization - Incomplete education and training on performing hand hygiene with gloves Environment - Location of ABHR dispenser not practical Task - Difficult HCW; ambiguity on performing hand hygiene on gloves vs hands Potential consequences 1. Incomplete disinfection Potential solutions for risk mitigation • Both visual and verbal cues should be provided. • Recommend fully extending arms during this step. • Empowerment and assertiveness training for TO/DA to speak up if actions deviate from safe practice/ verbalized instructions
7 336 378
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