Respiratory Practices in the Long-term Care Setting: A Human Factors-Based Risk Analysis.

Objective: To systematically assess safety risks pertaining to tracheostomy care in the long-term care (LTC) setting using a human factors engineering approach.

Design: We utilized a 5-part approach to complete our proactive risk assessment: (1) performed a hierarchical task analysis of the processes of tracheostomy stoma and suctioning; (2) identified failure modes where a subtask may be completed inappropriately; (3) prioritized each failure mode based on a risk priority scale; (4) identified contributing factors to and consequences for each of the prioritized failure modes; and (5) identified potential solutions to eliminate or mitigate risks.

Setting: Three high-acuity LTC facilities with ventilator units across Maryland.

Effect of an Intervention Package and Teamwork Training to Prevent Healthcare Personnel Self-contamination During Personal Protective Equipment Doffing.

Background: More than 28 000 people were infected with Ebola virus during the 2014-2015 West African outbreak, resulting in more than 11 000 deaths. Better methods are needed to reduce the risk of self-contamination while doffing personal protective equipment (PPE) to prevent pathogen transmission.

Methods: A set of interventions based on previously identified failure modes was designed to mitigate the risk of self- contamination during PPE doffing.