Poor compliance with standard and transmission-based precautions, such as handwashing, the use of personal protective equipment (PPE), and droplet precautions, is well documented, but the circumstances under which such failures of compliance occur have not been well described.

Researchers conducted a study to identify and characterize failures in precaution practices that could result in self-contamination or disease transmission during routine hospital care. They observed health care personnel outside and inside patient rooms in which precautions had been mandated to prevent the transmission of pathogens through contact or respiratory droplets.

A total of 325 observations were performed at two medical centers, on medical-surgical units, in ICUs, and (at one center) in an ED. Observers recorded more than 280 active "failures" associated with a risk of self-contamination or direct or indirect transmission of an infectious agent, classifying them as violations ("intentional deviations from recommended practices, procedures, standards," such as entering the room without PPE; n = 102), mistakes ("failures of intention [that] often occur when the plan for dealing with a problem does not achieve the intended outcome," such as removing PPE while holding something; n = 144), or slips ("failures of execution that generally indicate lack of attention or memory-related failures during the automatic performance of routine tasks," such as touching one's face with contaminated gloves; n = 37).

The circumstances or situations under which these failures occurred varied widely, even with similar types of failures. For instance, violations might involve a health care worker entering a patient's room to talk with a patient, check a device, or merely drop off some equipment. Mistakes, which most often involved PPE removal, could involve challenges with in-room computers or "difficult logistical situations." Slips, which involved "highly automatic behaviors," might occur during a conversation or when a cell phone rang.

Because these circumstances varied so widely, the authors suggest that a range of strategies-behavioral, organizational, and environmental-may be needed to reduce the potential for transmission during routine hospital care.

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