During one of my clinical placements, I observed a colleague who inadvertently failed to follow proper Infection Prevention and Control practices. While assisting with morning care for a patient on contact precautions due to MRSA, the nurse entered the room wearing gloves but forgot to don a gown. She proceeded with routine care tasks such as repositioning the patient and handling linens without realizing the breach.

Although her actions were unintentional and based on being rushed during a busy shift, this lapse could have led to serious negative outcomes. Without the proper PPE, there was a risk of MRSA transmission from the patient’s skin or environment to the nurse’s uniform. This, in turn, could have spread the pathogen to other patients, staff, or even the nurse’s own family.

Failing to follow IPAC protocols compromises patient safety, increases the risk of healthcare-associated infections, and contributes to the spread of antibiotic-resistant organisms. It also jeopardizes institutional trust and may lead to regulatory consequences or outbreaks requiring public health intervention.

After noticing the error, I gently reminded the nurse of the required PPE, and she quickly corrected it. We later discussed the situation and the importance of slowing down and remaining vigilant, even during high-stress periods. This experience reinforced my understanding that infection control is a shared responsibility, and adherence to IPAC standards is crucial in protecting vulnerable patients and maintaining a safe care environment.

One experience I had was in the middle of the COVID-19 pandemic, I saw a colleague forget to do hand hygiene after taking off their gloves. It was a very busy shift, and we were short-staffed. After helping one patient, they moved on quickly to the next task without cleaning their hands.
At the time, it may not have seemed like a big deal because gloves were used. But during COVID, every step of infection control is very important. Sadly, the unit went into outbreak the next week. Looking back, small mistakes like that may have helped the virus spread.
This experience taught me how important it is to always follow IPAC practices, even when we are tired or in a rush. A small action can make a big difference in keeping patients and staff safe.

Lapses in judgment can occur when healthcare providers are overwhelmed with multiple tasks and responsibilities – potentially compromising patient safety through lapses in IPAC practices. One common, yet often overlooked, example – one I’ve personally been guilty of – is the failure to properly decontaminate shared equipment such as vital signs machines, stethoscopes, or glucometers. These tools, when not adequately cleaned, can become vectors for the transmission of harmful microorganisms.
In my unit, we experienced a nosocomial outbreak of Vancomycin-Resistant Enterococcus (VRE). While many clients may be asymptomatic carriers, this poses a significant risk in an oncology setting, where the patient population is immunocompromised and susceptible to systemic infections. Beyond the clinical implications, such outbreaks also place considerable strain on healthcare resources. Terminal cleaning of rooms, curtain replacements, contact tracing through client swabbing, and relocating patients to prevent further spread all contribute to increased workload and stress on an already busy unit.

It is very easy for lapses in our judgement during very busy situations for instance I have witnessed on unit where I was working, staff members provided care of a patient with C.difficile on contact precautions, without using proper hand hygiene of using soap and water , doff gloves used hand sanitazer and went ahead to assist the next patient.
In this situation a potential negative outcome is risk of spreaading C. diffcile and causing infection to the next patients. Yes we can be busy but ignoring proper hand hygiene when dealing with sturbon infections can spread infections very quiclky , hence proper use of hand hygiene is something we as nurses should continue to practice, and take all neccessary responsibility in order to protect , and prevent patients and colleagues from infections.
The situation shows that lapses in infection control can cause significant harm, the need of strict adherence to IPAC practices and fostering a great culture of accountability as safe nurse will protect patients and ourselves.

As an RPN, I understand the critical importance of following Infection Prevention and Control (IPAC) protocols, especially during outbreaks. However, I recall a situation during a COVID-19 outbreak on our unit where a colleague failed to adhere to proper IPAC practices, putting both patients and staff at risk. During the shift I observed another nurse enter a COVID-positive patient’s room to administer medications and initiate G-tube feeds without donning appropriate personal protective equipment (PPE). The nurse was not wearing any PPE. Although the task may have seemed brief and routine, this lapse significantly increased the risk of viral transmission.
The potential consequences of this action were serious. Firstly, the nurse risked being exposed to COVID-19 and becoming a vector for spreading the virus to other patients especially immunocompromised individuals or those with multiple comorbidities. Next, not following proper hand hygiene and PPE protocol could have resulted in cross-contamination, especially when moving on to care for other patients. Lastly, such incidents undermine the trust and safety culture of the healthcare environment, and they can contribute to staff shortages if exposure leads to isolation requirements. This was an educational experience, and served as a reminder of how even small oversights in IPAC practices can have widespread and severe outcomes. It emphasized the need for ongoing education, peer accountability, and a consistent commitment to safety, even in a busy setting, or when feeling fatigued.
As nurses, our actions have direct consequences for our patients who are a vulnerable populations. Adhering strictly to IPAC guidelines is not optional, however a fundamental responsibility.

As a new graduate RPN working my first few weeks at a long-term care home, I was completing my morning rounds when I noticed a Personal Support Worker (PSW) preparing to enter a patient’s room who was on droplet and contact precautions for suspected COVID-19. The PSW was not wearing the required personal protective equipment (PPE)—specifically, no gown, gloves, or face shield—only a surgical mask.

Recognizing the risk, I respectfully intervened and reminded the PSW that the patient was on precautions and proper PPE must be worn before entering. I explained that this was essential not only for their safety, but also to prevent cross-contamination and protect other clients and staff. The PSW was appreciative of the reminder and immediately donned the appropriate PPE before entering the room.
If I hadn’t intervened, the PSW could have:
– Contracted COVID-19 and unknowingly spread it to other residents, patients, or staff.
– Contributed to an outbreak within the facility, which is dangerous in settings with elderly or immunocompromised individuals.
– Put clients at risk by contaminating shared equipment, surfaces, or care environments.
– Violated institutional IPAC policies, possibly leading to disciplinary action or loss of public trust.

This experience reinforced for me the importance of speaking up, regardless of my level of experience. Infection Prevention and Control (IPAC) is everyone’s responsibility, and even as a new grad, my actions can directly impact patient safety and staff well-being.

One time during a busy morning shift, I saw a co-worker forget to follow proper Infection Prevention and Control (IPAC) steps. They had just helped a resident use the toilet and then went straight to feed another resident without washing their hands or changing gloves. It may have seemed like a small mistake, but it could have led to serious problems.

Not washing hands or changing gloves between residents can spread harmful germs. In this case, if the first resident had an infection, it could have easily been passed on to the next one. Many of the people we care for in long-term care are older and have weak immune systems, so even a small infection can become very serious. It could lead to things like stomach bugs, pneumonia, or even outbreaks in the whole home.

There are also emotional and trust issues that come with not following IPAC. If a resident or their family finds out that someone got sick because a staff member didn’t follow the rules, it could hurt the relationship between the family and our care team. It also affects how safe residents feel in our care.

After this situation, our team talked about how important it is to speak up kindly when we notice a mistake. We also did more training and reminders about proper hand hygiene.

In the end, this reminded me that IPAC is not just about rules—it’s about keeping people safe. Even when things get busy, we have to take the time to do the right thing every time. It’s how we protect our residents, each other, and ourselves.

During my practicum, I had to shadow a nurse. That day, we had to perform wound care and wear PPE. When we finished, she spent some time explaining certain things to me. We left the room. I did the do-off, and after taking off my gloves, I washed my hands. But she just took off her gloves, grabbed others, and we moved on to the next patient without taking off her gown. Unfortunately, there was an infection control person on the unit that day who saw everything. This person emphasized that I, as a student, had done everything correctly, but the nurse hadn’t.
In this case, failure to exercise appropriate IPAC practices is crucial because not only the next patient but the entire unit was put at risk. Therefore, in our practice we must be aware of every step we take as well as the consequences that a single error can bring.

Think of a time you or a colleague did not follow IPAC practices. Discuss the situation and potential negative outcomes for clients related to not following the appropriate IPAC practices.

(Post your answer in the discussion below)

During one of my clinical placements, I observed that one of the staff nurses failed to perform hand hygiene after removing her gloves and proceeded to the next client to perform a wound dressing change. The potential negative outcomes for the next client could include the risk of infection, which may lead to delayed wound recovery. Also, with contaminated hands, this staff nurse could transfer pathogens to other surfaces, such as door knobs, and increase the risk of transmission across other clients and staff.

Situation:
During a series of home visits, a colleague was running behind schedule and forgot to disinfect the blood pressure cuff between clients properly. The nurse had just finished visiting a client with a known MRSA-positive wound. Then the nurse used the same blood pressure cuff on the next visiting client, who was an elderly client recovering from chemo treatment was diagnosed with neutropenia, and this client needs extra caution of prevention. However, the nurse forgot to use a barrier or clean the cuff.
The Potential Negative Outcomes for the Client:
Infection Risk: The second client was immunocompromised, making the client more vulnerable to infection. The MRSA bacteria could have been transferred via the cuff or the nurse’s hands, leading to easily spread and complications to the next client.
Delayed Recovery: If infected, this client could have experienced delayed recovery, possibly needing further medical treatment, antibiotics, or even hospitalization.
Loss of Trust: If the client or family noticed inconsistent hygiene practices, it could undermine their confidence in home care services and the nurse-client relationship.
Spread of Infection: Improperly cleaned equipment could contribute to the spread of antibiotic-resistant bacteria among vulnerable populations visited that day.
Reflection and Learning:
This situation led to a team debrief, where it was emphasized that even when under time pressure, IPAC must remain a top priority. A checklist was introduced for cleaning equipment between visits, and the team received refresher training on infection control in the community setting, especially with resistant organisms.

During my internship, I had to shadow a nurse. That day, we had to care for a patient who had MRSA positive wound, so we had to wear full PPE. After finishing, the nurse explained a few things to me. We left the room. I do-off the PPE and, after removing my gloves, washed my hands; However, she simply took off her gloves, sanitized her hands, took another ones, and moved on to the next patient without removing her gown. Unfortunately, there was an infection control person on the unit that day who saw everything. This person emphasized that I, as a student, had done everything correctly, but the nurse hadn’t, and the charge nurse was notified with consequences.

In this case, the nurse did not follow proper IPAC practices. She was not accountable to following the principles of nursing practice which states that patient’s safety and well-being is crucial when caring for patients (College of Nurses of Ontario [CNO], 2025). She put at risk not only the next patient but also the unit.

Hi Carolina,

Thank you for sharing your experience. As a nursing student, you have demonstrated awareness and accountability by following IPAC practice, especially in that high-risk situation where the patient has MRSA. The staff nurse may be too busy to change a new gown; however, this action puts other patients and staff at great risk in that healthcare environment.

During my time working as a nurse, I’ve observed a level of complacency regarding infection control practices. One example involves a patient with a confirmed case of MRSA, where contact precautions are required for care. However, I have noticed instances where coworkers only wear gloves, and not don a gown. This not only puts the individual at risk but also increases the potential for the spread of infection to other patients and staff. I always take the opportunity to remind my coworkers of the importance of adhering to proper PPE protocols, reinforcing that infection control is everyone’s responsibility.
I believe this issue partly stems from the idea that “nothing bad will happen” or “I won’t be the one to spread it.” I think this mindset develops where providing daily care can lead staff to become desensitized to the risks.

During an influenza outbreak at my workplace, I was passing by a room of an isolated client. A PSW was providing care without proper PPE. I immediately donned my PPE and asked her to step out to put on her proper PPE, and I would help her finish the care. Due to time constraints and heavy workload, we sometimes overlook the importance of PPE and prioritize care. It is important to educate and remind people of the importance of proper PPE to protect not just ourselves but also other people around us. That is our shared responsibility as humans.