184
Table 3. (Continued ) Step
4.1 Remove outer apron by untying apron strap
Ayse P. Gurses et al
Failure Mode
Assistant does not perform hand hygiene after untying strap
Severity Probability Detectability RPN 85 8
320
Contributing factors Person - TO is paying too much attention to the HCW at the expense of DA; HCW and DA do not have adequate spatial and self-awareness Tools/Technology - Type of apron (one that is not a tear-away type), must be removed over the head or may require assistance to remove Environment - More likely to bump into HCW when the space is small Task - Assistant helps with task that is not necessary; no guidance on how to remove a grossly contaminated apron Potential consequences 1. Risk of assistant contamination Potential solutions for risk mitigation • HCW should be removing apron by themselves before entering the doffing area (if you cannot because of space, need to add a disinfectant step); second most contaminated PPE
• Only use aprons where the HCW worker is able to pull off outer apron individually • If those are not available, should cut off apron rather than pulling over head
Note. TO, trained observer; HCW, healthcare worker; DA, doffing assistant; PPE, personal protective equipment; ABHR, alcohol-based hand rub.
Table 4. Example of Synthesis of Risk Mitigation Strategies Worksheeta Category Definitions and Examples Training/Education
Teamwork skills
Training and education aimed at enhancing the interactions between the HCW, TO, and DA
Risk Mitigation Strategyb
5. Team members should utilize assertiveness techniques and speak up if they are unsure or uncomfortable (13, 21, 25, 31, 53, 56, 68, 69, 95, 98, 100, 101, 102)
6. Ensure all team members know the roles and functions of all team members engaged in the doffing process (13)
7. Practice communication and information exchange between (eg, closed-loop communication) the TO, DA, and HCW, beyond simple dictation of steps (13, 70, 75)
8. Training should include back-up behaviors and cross-checking between all team members, not just the HCW (14, 26, 29, 31, 33, 36, 37, 44, 98)
9. HCW should be turning around to help TO/DA with assessment (15, 16)
10. Need to avoid overreliance on the expectation that the HCW is able to identify contamination and DA/TO do not need to pay as close attention (15, 16)
11. All team members should be cross-trained to enhance the mutual understanding of all roles and responsibilities.
Note. TO, trained observer; HCW, healthcare worker; DA, doffing assistant. aThe complete list of risk mitigation strategies can be found in the supplementary material (Appendix 3 online). bNumber denotes the corresponding failure mode(s) in Appendix 2 (online).
Several strategies were identified to improve safety of the PPE
doffing task itself. Participants pointed to the importance of employing all team roles as outlined by the CDC guidance; asking 1 person to perform the duties of both TO and DA hinders their ability to perform effectively. Participants also identified strategies to eliminate unnecessary steps and to improve the clarity of instruc- tions. Improving steps involved with removing the gown (eg, folding back the gown to avoid touching outer surfaces), gloves, apron, and PAPR hood were noted as having the greatest potential impact.
Discussion
Failure modes while doffing PPE can lead to HCW contamina- tion, and potentially severe or fatal consequences. Using HF methodology, we systematically mapped the complex PPE doffing process and identified 103 ways the doffing process can fail, leading to self-contamination. Among these failure modes, 54 were identified as priority areas. Findings from this analysis led to the following conclusions. 1. Safely doffing PPE requires knowledge, skills, and attitudes
beyond the basic instructions for when and how to remove PPE elements.
The CDC guidance focuses on the correct technique and
sequence of removal of each PPE element. This FMEA revealed important competencies beyond these technical aspects of PPE removal. First, exposure to high-consequence pathogens can invoke feeling of stress for team members. This stress can be exacerbated if a team member commits an error or must respond to a novel circumstance, if there are large amounts contamina- tion, or if a PPE breach occurs. The negative effects of stress are well-known across research domains,29–31 and managing stress is an important skill that can be gained through training.32 There- fore, organizations should consider integrating task perturbations and error-recovery opportunities33,34 into training scenarios so team members have the opportunity to practice recognizing and recovering from these types of situations. Additionally, training should aim to provide competency in identifying and assessing risks from an infection prevention and control standpoint during doffing. Current PPE guidelines focus on the role and actions of the HCW, with less emphasis given to skills required to safely fulfill the TO and DA roles. The FMEA revealed many teamwork skills underlying safe doffing such as effective communication and information exchange, assertive- ness, and role clarity. Evidence demonstrates the effectiveness of team training on improving clinical staff’steamwork skills as
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