Human factors–based risk analysis to improve the safety of doffing enhanced personal protective equipment

Abstract

ObjectiveTo systematically assess enhanced personal protective equipment (PPE) doffing safety risks.DesignWe 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.SettingA large academic US hospital with a regional Special Pathogens Treatment Center and enhanced PPE doffing protocol experience.ParticipantsEight IP experts.MethodsThe 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.ResultsOf 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.ConclusionsDespite 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.

Personal protective equipment doffing practices of healthcare workers

“…[13] Although more complex than the PPE ensembles used in transmission-based precautions, human factors analyses of the doffing process for enhanced PPE ensembles used to care for patients with EVD, have highlighted numerous opportunities for PPE failure and self-contamination. [3] Gurses et al [14] concluded that safe doffing of PPE requires knowledge, skills and attitudes, not just instructions for the sequence and technique for how to remove pieces of PPE. Our observations suggest that HCWs are not familiar with the sequence and technique for how to remove pieces of PPE, but training that builds knowledge and skills and changes attitudes may motivate HCWs to utilize the correct sequence and technique.…”

Human Factor Considerations in Using Personal Protective Equipment in the COVID-19 Pandemic Context: Binational Survey Study

“…The doffing sequence is the reverse. Improper use of PPE is known to spread infection among health care workers [ 4 , 5 ]. All these steps can be sources of errors.…”

“…Previous research on using full PPE in various contexts (chemical, biological, radiological, nuclear and explosive incidents, firefighting, health care, and the military) has shown several human factor problems. Much of the research addressed procedural problems, including failures to effectively put on (don) or remove (dof) the PPE [ 2 - 5 ], and ergonomic problems such as poor fit and discomfort while having it on [ 6 - 9 ]. Problems of ineffective use or decreased adherence to using the PPE were found to be associated with insufficient training and lack of prior experience [ 10 - 13 ], and with the appropriateness of organizational culture [ 12 , 14 - 16 ].…”

Healthcare Workers’ Strategies for Doffing Personal Protective Equipment

“…Our findings indicate that PPE should be redesigned in ways that facilitate expedient and safe doffing methods. Design cues could help HCWs envision and execute appropriate doffing methods; for example, color-coding PPE surfaces to differentiate “dirty” outside surfaces from “clean” inside surfaces could help HCWs track where these surfaces are at each step of the doffing process [16, 27]. Fasteners (eg, straps, belts) that do not require untying and are easy to undo (or rip) quickly would facilitate speed and ease of doffing [16, 27].…”

“…Design cues could help HCWs envision and execute appropriate doffing methods; for example, color-coding PPE surfaces to differentiate “dirty” outside surfaces from “clean” inside surfaces could help HCWs track where these surfaces are at each step of the doffing process [16, 27]. Fasteners (eg, straps, belts) that do not require untying and are easy to undo (or rip) quickly would facilitate speed and ease of doffing [16, 27]. PPE also must fit people of different sizes and physical abilities and should be either adjustable or available in several sizes [14, 27].…”