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.