[Grace]

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)

[Grace]

Hello Everyone,

I hope you are all looking forward to starting the IPAC course and are ready for more learning.

This course is asynchronous with 1 module each week.
Each week, you are required to review a module and all its contents (readings, videos, activities and the knowledge check) post in discussions and respond to at least one of your peer posts.
Instructions are provided in the module each week as to what activity is required for each module. The instructions are posted within the module/discussion post section, so make sure you access each module each week to not miss any.
There will be an assignment in the final week, and instructions will be provided as well.

You are expected to participate and complete the modules each week. The discussion post is being monitored to ensure participation and receipt of certificate.
We understand that your other commitments may prevent this for some weeks; if you miss a week, please catch up the following week in addition to that week’s content.

I look forward to all the great ideas and postings for each weekly module.

Thank you,
Grace

[Wenpeng]

I can still remember an incident in which a staff did not follow the IPAC precaution for serving a patient with a fresh wound that caused the patient had another episode of infection.

It was a busy unit and one nurse was assigned to various patients scattered around the unit. Plus there was staff shortage as well. One of the staff was assigned to a patient who had a surgery. The assigned staff was to change the wound dressing, meanwhile, the staff just helped the other patient and forget to change the gown. The staff was able to follow the sterile procedure for wound dressing change, however, there was an infection two days after noticed on the patient.

The team had meetings for the infection and figured out the unchanged gown for this patient. There was a debrief after the incident, and all the reflection signage was on the door of each patient’s room. A further education was provided to all the health team staff after that.

[Gladys]

Hi Wenpeng,
Thank you for sharing your experience. It’s a powerful reminder of how even small mistakes, can have serious consequences for our patients. I can imagine how challenging it must have been for the staff, trying to juggle so many responsibilities with a shortage of hands.
I like the idea of adding reflection signage to patient doors, it’s such a simple but effective way to keep infection control at the forefront of everyone’s mind. It’s also reassuring to hear that the team came together to reflect on the situation and prioritize education to prevent similar issues in the future.
Your story is a good reminder for all of us that adhering to IPAC practices is crucial, especially when dealing with vulnerable patients like those with fresh surgical wounds. Thanks again for sharing

[Terry]

Wenpeng thank you for sharing your experience. This example is excellent, being able to investigate and find the cause of the additional infection is amazing. The Debriefing process is critical to understand the route of transmission, and the details of the incident. This reinforces the importance of the IPAC team and all of the protocol that are in place for everyone’s safety.

[Gladys]

During my recent field placement at a long-term care home, I witnessed an incident that reminded me just how important it is to follow infection prevention and control (IPAC) practices. A colleague went into the room of a symptomatic resident under droplet and contact precautions without wearing the proper personal protective equipment (PPE). The resident had tested negative on a rapid COVID-19 test but was still waiting for confirmatory results. Unfortunately, the staff member forgot to wear an N95 mask and eye protection before entering.
When the colleague realized the mistake, he quickly left the room, reported the incident to the charge nurse, and thoroughly sanitized his hands. After putting on the correct PPE, he returned to provide the necessary care. The incident was reported, and the team reviewed infection control protocols to ensure everyone stayed on the same page.
This situation could have had serious consequences. COVID-19 spreads so easily, and this exposure could have put staff and residents at risk. In a long-term care home, where many residents are elderly or have underlying health issues, an outbreak could lead to severe illness or worse. It would also add pressure to an already stretched team and potentially shake the trust families have in the care we provide.
What happened that day was a powerful reminder of how crucial it is to stay vigilant about following proper precautions, especially in environments where the stakes are so high. It was also a learning moment for everyone involved, reinforcing the importance of using PPE correctly and taking responsibility to protect ourselves and those we care for.

[Kimi]

Hello Gladys,
Thank you for sharing the story. I agreed that using PPE is protecting us and patients. I can relate that sometimes on the busy day in hospital, staff tried to deliver the food tray without wearing any PPE in droplet room. People may think few second of entering would not cause any issue. But this small action could actually lead to severe consequent as not following the proper precautions. The droplet pathogen can still remain in the air and land on the staff even with few second of entering the room. Then the spread could start from there. It is important to follow IPAC policy and wear PPE when entering the isolation room.

[Kimi]

An example was a nurse cared for a patient with C.diff. The nurse had PPE on when performing care, but neglected to wash hands after removing the PPE and immediately moved to care for next patient who were calling for help. The potential negative outcomes would be the next patient could develop C.diff as the nurse may carry the pathogen. This is considered as healthcare associated infection, which can cause longer hospital stays and even mortality in severe cases. Moreover, this nurse could spread the C.diff to the next patient, increasing the risk of infection for vulnerable individuals, especially patients with chronic conditions and immunocompromised disease. In order to reduce or avoid such situations, it is mandatory for nurses to attend regular training and education on the importance of hand hygiene and maintain environment and equipments disinfected frequency. PPE should be used according to infection control policy.

[Rose]

Hello Kimi,
Thank you for your post. It is indeed important to follow infection control policies. The nurse caring for a patient with C. diff made a mistake by not washing her hands after taking off her PPE. This could lead to the next patient getting C. diff, which is a serious infection that can cause longer hospital stays and even be life-threatening for some people. To prevent this from happening, it’s crucial for all nurses to remember the importance of hand hygiene. Regular training on infection control practices can help everyone stay informed about the best ways to keep patients safe.
It might be helpful to have reminders in the workplace, like posters about handwashing and proper PPE use. Also, to create a system or workplace culture where nurses can remind each other to wash their hands after removing PPE could be beneficial. At the end of the day, keeping our patients safe is a team effort, and we all need to help one another and do our part to prevent infections! Thank you.
Best, Rose

[Judy]

Hi Kimi,

Thanks for sharing your experience. Hand washing is so important, to further this for C.Diff you have to use soap and water to reduce the risk of infection. I find it frustrating at times because there is no garbage bin near the sink and I find that house keeping tends to forget to refill the soap on those dispensers.

[Wenpeng]

Hi Kimi,

Thank you for sharing the story. Yes, I agree with what you mentioned in your post. The staff was in a rush to help another patient after serving a C. diff patient that could possibly transmit the C. diff to the other patient, which could be prevented from happening if IPAC precaution could be strengthened during practice and education.

The education part for staff should be reinforced and mandatory for a certain interval. It is usually provided annually; it could be planned shorter, say six months. Staff could have a refresh before foregeting the IPAC precaution.

[Tammy]

A colleague once failed to wash their hands before changing a patient’s wound dressing and later touched personal items without sanitizing their hands. This lapse in Infection Prevention and Control (IPAC) practices posed a risk of cross-contamination, potentially transferring pathogens from the wound to other surfaces or the patient, increasing the likelihood of infections such as cellulitis or sepsis. Additionally, pathogens from other patients or environmental surfaces could have been spread, leading to healthcare-associated infections. Such failures in IPAC not only harm individual patients but can contribute to broader outbreaks, extended hospital stays, and complications, highlighting the critical importance of adhering to proper hygiene protocols in healthcare settings.

[Mary]

Hi Tammy
Thank you for sharing this example. It really highlights the serious risks associated with lapses in IPAC practices. Cross-contamination can have devastating consequences, especially for vulnerable patients. Ensuring proper hand hygiene before and after wound care is essential in preventing infections like cellulitis and sepsis. Have you encountered any specific strategies or interventions that helped reinforce adherence to IPAC protocols in your workplace?.

[Mary]

Hello Everyone,

During a COVID-19 audit, when I was placed at a certain long-term care during my clinical pre-grade placement. I observed a staff entering the room of a patient under airborne and droplet isolation without performing hand hygiene. I found this to be a significant breach of Infection Prevention and Control (IPAC) practices, as proper hand hygiene is the first line of defense against the transmission of infectious diseases.
The staff failing to perform hand hygiene before entering an isolation room could have introduced pathogens into the patient’s environment, increasing the risk of infection. Additionally, if the staff touched surfaces in the isolation room and then moved on to clean other areas without sanitizing their hands, they could have unknowingly spread infectious agents to other vulnerable patients. Cross contamination can occur for high risk patients’ example, Immunocompromised patients or those with comorbidities.
I believe failure to follow IPAC protocols in a healthcare setting can contribute to an outbreak, affecting multiple patients, staff, and visitors, ultimately leading to increased morbidity and mortality.

[Rose]

Last year, while I was working on a stroke rehabilitation unit, we had a situation where we didn’t follow Infection Prevention and Control practices properly. We had a patient who had been exposed to MRSA and another patient who was MRSA positive. Even though the exposed patient tested negative, IPAC guidelines stated that we needed to keep them in contact isolation until we had further confirmation.
One of my colleagues thought that since the test was negative, we could take the patient out of isolation. When he left the room, he asked me to help by removing some trays from the patient’s table. I went into the room without putting on my gown, which was a big mistake since I was close to the patient.
Not following these precautions could have put other patients at risk by spreading MRSA. This experience made both my colleague and me realize how important it is to follow IPAC guidelines. We learned that we should always check a patient’s precautions and make sure everything is clear with IPAC before making any changes. This incident reminded us how crucial IPAC is for keeping all patients safe.

[Kim]

Hello Rose, Yes I agree to your post. IPAC guidelines should be implemented in this situation because it causes Broader Health Consequences such as:

Development of respiratory outbreak in the facility
Multiple residents requiring isolation
Worsening of chronic conditions in affected residents
Increased risk of aspiration pneumonia
Need for transfer to acute care facilities

[Judy]

This is such an important aspect of care planning. We have seen the results from COVID and the rational as you why we need IPAC. During clinical one of the students was running in her PPE out of her room because she forgot something and the clinical instructor brought it up. The clinical instructor told us to use it as a learning experience, having someone outside the door is an easy way to help decrease this incident. The risk of causing an outbreak increases when proper precautions are not followed and this can increase risk for already immunocompromised patients.

[Wafaa]

Hello Judy,

Thank you for sharing your experience, You are absolutely right! IPAC is so important, especially after what we learned from COVID-19. The example you shared shows how easily mistakes can happen, like running out of a room in PPE. It is great that the instructor used this as a learning moment for everyone. Having someone outside the door to help is a simple way to make sure everyone follows the right steps. Small mistakes like this can lead to bigger problems, especially for patients with weak immune systems. This reminds us how important it is to always follow IPAC rules to keep patients safe and avoid outbreaks.

[Wafaa]

During my clinical placement as a nursing student in a medicine floor, I observed an agency PSW assisting a patient with toileting. After completing the task, she went straight to adjust the patient’s bed without changing her gloves or sanitizing her hands. She also touched various surfaces in the room, before leaving. This lack of hand hygiene could have caused harmful bacteria to spread, putting the patient at risk of infection, especially considering their already weakened immune system. It also raised the possibility of cross-contamination to other patients or surfaces in the facility.
I decided to speak to her privately and gently reminded her of the importance of following IPAC practices, like changing gloves and washing hands between tasks. She appreciated the feedback and acknowledged the mistake. This experience reinforced the critical need for all healthcare workers, regardless of their role, to adhere to infection prevention protocols to ensure patient safety.

[Olubukola]

I agree, it is often forgotten that an adequate hand hygiene is still required even with gloves being worn.

[Olubukola]

One of the common ones is when a staff puts on a set of PPE, goes into patient’s room, and forgets to pick something important for the intended procedure, then runs back to quickly grab it without removing the PPE. This often potentially causes the transfer of infectious agent from the PPE to the clean area outside the infected patient’s room.

Therefore, it is often advised to take that extra minute to take off the PPE and put on a new set upon re-entry, or call a colleague to grab the forgotten item to ensure infections are not being transmitted to other susceptible hosts.

[Terry]

In a previous med/surg placement, I witnessed a nurse caring for a patient with isolation precautions in place, the nurse stepped out of the isolation room in full PPE, because the vitals machine was in the hall. She came out of the room, quickly walked about 5 steps and grabbed the vitals machine and returned to the room. The nurse had many options the could have used, they could have pushed the call bell, and a coworker would have come to the door way of the room and could have obtained this for them, they could have just called out for a colleague to assist also.
Coming out of the room in full PPE compromises other vulnerable patients, visitors and co workers, regardless of how quick they were. As nurses we have an ethical obligated of Nonmaleficence in our daily practice.

[Author]

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