The medical community is losing its biggest gun in fighting infection, antibiotics. Researchers are turning to safety protocols to reduce the transmission of antibiotic-resistant organisms, like Clostridium difficile, methicillin-resistant Staphylococcus aureus (MRSA), and influenza. The health-care environment, however, may be setting health-care workers up for failure.

During 325 observations, researchers at the University of Utah and University of Michigan identified 283 protocol violations, which could increase the risk of self-contamination of health-care personnel and transmission of antibiotic-resistant organisms to patients. The results of the study are published in the June 11 issue of JAMA Internal Medicine.

“We already know from other studies that there are breaches in practice,” said first author Sarah Krein, PhD, RN, research professor at University of Michigan and research investigator at the Veterans Affairs Ann Arbor Healthcare System. “Our team was interested in understanding why and how those breaches occur so we can develop better strategies to ensure the safety of patients and health-care personnel.”

During a 9-month period, 11 staff observed health-care professionals at 2 locations. At one location, 280 observations were conducted in medical-surgical units (196), intensive care units (64), and the emergency department (20). At the second location, 45 observations were made in medical-surgical units (36) and intensive care units (9).

“We were observing highly trained and motivated people working in a complex system that has issues,” said Frank Drews, PhD, professor in the Department of Psychology at the U and senior author on the paper. “We want to encourage health-care decision-makers to make improvements to the system so it is easier for health-care workers to adhere to best practices.”

The observation staff used Reason’s model of human error to classify errors as violations, mistakes, or slips.

Violations occurred when personnel did not follow standard health-care interaction protocols. Of the 102 violations, many occurred when the health-care personnel did not put on the appropriate personal protective equipment, like gowns, gloves, and masks, because they did not plan to interact with the patient or the family. Other violations were observed when checking devices or dropping off supplies in patient rooms.

Mistakes were classified as errors in process or procedure. The 144 mistakes consisted of taking off gowns in the improper sequence, touching gloved hands to an ID badge to log into in-room computers, and using gloved hands to retrieve medications or supplies from coat pockets.

Finally, the observers classified slips as inadvertent automatic behaviors. Of the 37 observed slips, the researchers identified actions like health-care personnel touching their face with a gloved hand or using personal devices.

“At the core of our work is the idea that we need to be even more thoughtful about the type of equipment that we introduce in health care. More usable equipment will make it easier for health-care workers to do their tasks and keep their patients safe,” Drews said. “We want to make real fixes to the system, not just put a band-aide here or there.”