[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 to learn more.

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 peers.
Instructions are provided in the module each week on the required activity for that module. The instructions are posted within the module/discussion post section, so be sure to access each module each week to avoid missing any.
There will be an assignment in the final week, and instructions will be provided.

You are expected to participate in and complete the modules each week. The discussion post is being monitored to ensure participation and receipt of the certificate.
We understand that your other commitments may prevent you from completing 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 your great ideas and postings for each weekly module.

Thank you,
Grace

[Mildred]

During a busy shift on a medical unit, I observed a colleague move quickly from one patient room to another without performing hand hygiene after removing gloves. The colleague stated they were behind on tasks and intended to “wash later.” Although gloves had been worn, proper IPAC practices were not followed because hand hygiene is required before and after every patient interaction, regardless of glove use.

Failing to perform hand hygiene can lead to the transmission of microorganisms between clients, particularly among vulnerable populations, including older adults, immunocompromised patients, or those with surgical wounds or invasive devices. Potential negative outcomes include healthcare-associated infections (HAIs) such as urinary tract infections, surgical site infections, or the spread of organisms like C. difficile or MRSA. These infections can result in prolonged hospital stays, increased use of antibiotics, delayed recovery, and in severe cases, serious complications or death.
This situation highlights how time pressure and workload can contribute to lapses in IPAC practices. However, consistent adherence to IPAC standards is crucial to protect client safety, maintain trust, and prevent avoidable harm. It reinforced for me the importance of prioritizing infection prevention measures, even during high-stress or complicated situations.

[Carla-Jane]

During one of my clinical placement at a Long term Care Facility, i observed as one of my colleague follow appropriate IPAC procedure as regards sharing medical equipment. She used a blood pressure cuff and thermometer on one resident and used the same equipment on another resident without cleaning or disinfecting it in-between use.

According to IPAC Canada, shared patient-care equipment must be cleaned and disinfected between uses to prevent cross-contamination and transmission of pathogens (IPAC Canada 2023).
The negative outcome from not practicing proper IPAC procedure are Cross-contamination between residents especially as LTC has elderly residents who have weakened immune system, increased healthcare costs and resource use , compromised client safety and trust because resident expect healthcare workers to follow safety protocols.

This experience emphasized my responsibility to prioritize client safety, model best practices, and advocate for adherence to IPAC standards.

[Sara]

During my clinical placement, I observed that medical equipment was not always appropriately cleaned between patients, particularly during shift changes. This raised concerns about infection prevention and patient safety. I later brought this issue forward during an interdisciplinary meeting. In my opinion, one of the contributing factors was the limited availability of medical equipment. Because of this shortage, staff often felt rushed to return equipment quickly for use by other staff members or in emergency situations. As a result, even when disinfectant wipes or solutions were used, the equipment was not always given the required contact time to air-dry. Many disinfectants require at least one minute of contact time to be fully effective, and this was not consistently being followed.
In this situation, the nurse has a professional responsibility to advocate for patient safety in accordance with the CNO Code of Conduct. This includes speaking up about unsafe practices, ensuring proper infection control measures are followed, and raising concerns to management and administration when systemic issues—such as inadequate equipment supply—are identified.

According to the CNO Code of Conduct, nurses are expected to work collaboratively, promote a culture of safety, and advocate for the resources necessary to provide safe, ethical, and competent care. Addressing this issue supports not only patient safety, but also teamwork and professional accountability.

[Mujidat]

You raise an important and very realistic concern regarding infection prevention and control, especially during busy transition periods such as shift changes. Inadequate cleaning of shared medical equipment is a well-documented risk factor for healthcare-associated infections, and your observation about insufficient contact time for disinfectants is particularly significant. As you noted, even when cleaning products are used, failure to allow proper air-drying can significantly reduce their effectiveness and place patients at risk.
I also appreciate how you identified systemic factors, such as limited equipment availability, rather than placing blame on individual staff members. This reflects a strong understanding of how organizational constraints can influence practice. Your decision to bring the concern forward during an interdisciplinary meeting shows professional accountability. It aligns well with the CNO Code of Conduct, which emphasizes advocacy, collaboration, and promoting a culture of safety.

[Mebo]

Hello Sara
Thank you and I strongly agree with your point that nurses should continue to advocate for proper resources so that they can safely provide care
that will protect patients from aquiring disease that are preventable if enough resouces are readly available.

[Mujidat]

One of the incident i can remember is when a Personal Support Worker (PSW) entered a resident’s room to assist with feeding while the resident was on contact precautions. Due to being rushed and focused on completing scheduled care, the PSW forgot to don the required gown and gloves before entering the room.

Contact precautions are implemented to prevent the spread of microorganisms that can be transmitted through direct contact or contact with contaminated surfaces. By not wearing the appropriate personal protective equipment (PPE), the PSW increased the risk of transmitting infectious organisms from the resident to themselves, other residents, staff, and the environment. Contaminated clothing or hands could unknowingly spread microorganisms to shared equipment, door handles, or other residents.

The potential negative outcomes for the resident include re-exposure or worsening of their infection, while other residents—many of whom may be elderly or immunocompromised—are at risk of developing healthcare-associated infections. For the PSW, failure to follow IPAC practices also increases the risk of personal exposure and could lead to illness, time off work, or further spread within the facility.

[James]

Hi Mujidat
Thank you for your post. I work in long-term care and have to do PPE and hand hygiene audits regularly. I observe other staff forgetting a step in donning and doffing which is concerning. I also think that low staff to patient ratio contributes to these mistakes causing increased stress and the expectation to get things completed on time. I also think that constant education can encourage staff to follow infection control measures more effectively in order to protect our residents/patients from infectious organisms.

[Mebo]

My experience working in Acute care, I have observed nurses using the wrong PPE entering isolation room, especially not waering gown during contact and droplet precautions in place. This place immediate cross-transmission of pathogens between patients , staff and the environment. Patients are at high risk of acquiring infectious diseases such as MRSA, VRE, C.difficile which can cause harm , prolong stay, and morbidity for patients.

[James]

During the first wave of the pandemic, I worked on a Covid unit. My clients were all Covid positive and experiencing symptoms. There were no vaccines as of yet and my clients were very sick. The fear of catching Covid crossed my mind constantly. I knew the only thing that I could do to protect myself was practicing proper donning and doffing of my PPE and frequent hand sanitizing. My shifts were 12 hours non-stop and I often would become exhausted towards the end. I remember coming out of a room and doffing and then going to my next client’s room and doffing everything but my mask and shield. I removed my mask because I had been wearing it for hours and it needed to be replaced. Once I got into the room, I realized that I wasn’t wearing a mask or a shield. The client had a fever and a productive cough. I immediately exited the room, removed my PPE, performed hand hygiene, re-donned my PPE including my mask and shield this time. That morning, I left work thinking that I had caught Covid and the anxiety stayed with me the days following. Thankfully I did not catch Covid, however I engaged in self reflection and thought about what the negative outcomes. From that day forward diligently made sure I was properly donning and doffing my PPE, performing hand hygiene, and making sure not to forget any steps in the process.
If a mask is required continuously in the workplace setting, it does not have to be changed unless it is dirty, wet, or difficult to breathe through. Furthermore, hand hygiene should always be performed while donning and doffing masks (Public Health Ontario, 2025). During the pandemic, I remember hearing the stories if mask shortages. Luckily, my workplace had no shortage of PPE and we were able to change our masks frequently.

[Nadine]

Hi James,

Thank you, I am glad you shared your story. Your sincerity is very admirable. Leaving the room, seeing mistake, and putting your PPE on again will indicate you know what to do even when under stress.

COVID shifts, particularly 12-hour shifts with extremely sick patients, are challenging to work, and it is too easy to forget a step when you are tired. This is why we need to develop good habits, they can ensure that our patients are safe as well as ourselves as healthcare workers.

I also appreciated the fact that you also thought over the mistake and ensured that the mistake was not repeated. This is exactly the correct course of action. Public Health Ontario (2025) makes us remember that hand hygiene must always be performed during donning and doffing, and your experience demonstrates the importance of that.

It is a good reminder that both the patients and the staff are safeguarded by IPAC practices, as it is mentioned in your post.

[Author]

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