[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

[Diana Ampate]

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.

[Shanna]

Hello Diana,

Thanks for sharing your experience. It shows how easy it is to miss a step in IPAC when things get busy. You did a great job reminding your colleague in a kind and respectful way. Even small mistakes, like forgetting a gown, can lead to the spread of infections like MRSA. This reminds us how important it is to follow all IPAC steps to keep patients, staff, and families safe. Teamwork and speaking up make a big difference.

[Nel]

Hi Diana!
Thank you for sharing. Your experience highlights the real-world challenges we face in maintaining strict adherence to IPAC protocols, especially in high-pressure environments. It is a powerful reminder that even well-intentioned oversights can have serious implications for patient and staff safety. Your respectful intervention not only prevented potential harm but also fostered a learning moment grounded in teamwork and accountability. This scenario reinforces the importance of vigilance, open communication, and mutual support in upholding infection control standards and ensuring safety.

[Mebo]

Thank you for sharing, and I agree we can get busy, however IPAC is very critical in our work enviroment. Mistakes can cause a bigger problem of spreading infections. I also really appreciate nurses like you steping in, and point out area that need improvement because in most cases that I have witnessed, nurses are afraid to correct colleagues when there is need to do so.

[Carolina]

Sometimes, as nurses, we are subjected to heavy workloads, especially in the mornings, where we have to complete several tasks for 5 to 6 patients in a short period of time, and this can lead us to make mistakes that put the health of our patients and ourselves at risk. Therefore, we must be aware of each step and, above all, evaluate it before taking the next step.
It was great that you had the opportunity to give feedback in a kind manner and she could correct it protecting the patients and the unit. This demonstrates how important teamwork and collaboration are during our practice.

[Mintesinot]

Hi Diana,
Thank you for sharing your experience from your clinical placement. You pointed out an important issue. That even small mistakes in Infection Prevention and Control (IPAC) can have serious effects on patients and healthcare workers.
It’s great that you noticed the mistake and handled it in a nice and positive way. By doing this, you helped fix the problem and also promoted a safe working environment. These reminders between colleagues are very important, especially during busy times when it’s easy to forget the rules.
Your reflection shows that IPAC is a responsibility we all share. Staying alert, even when things get hectic, is crucial to preventing infections in healthcare. The fact that you and your colleague took time to talk about how to avoid similar problems in the future shows your strong commitment to patient safety.
Thank you once again for sharing your experience. It reminds us how even small actions can greatly improve the quality of care and help with infection control.

[Shanna]

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.

[Diana Ampate]

Thank you for sharing that experience, Shanna. It highlights how even minor lapses in infection control, especially during a time like the COVID-19 pandemic, can have serious consequences. I agree—gloves alone don’t replace the need for proper hand hygiene. Your reflection is an excellent reminder of why it’s crucial to stay vigilant with IPAC practices, even when overwhelmed or short-staffed. It only takes one moment of forgetfulness to put others at risk. Thank you for emphasizing the impact of these everyday actions.

[Gemma]

Hi Shanna,
Thank you for sharing your experience. I completely understand how mistakes can be made when nurses are under pressure to provide care to all our patients, especially during the middle of the pandemic. Working in healthcare small missed steps can have profound impact, like how you stated your unit went into outbreak the week following this incident. This story you shared serves as a reminder to us all to slow down, and take the necessary infection control steps to protect ourselves and our patients.

[Nel]

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.

[Juana]

Your reflection clearly highlights the critical role that Infection Prevention and Control (IPAC) guidelines play in protecting both patients and healthcare workers. IPAC protocols, including the correct use of personal protective equipment (PPE), are designed to create barriers against the transmission of pathogens in healthcare settings. When these guidelines are not rigorously followed, pathogens like VRE can easily spread via direct contact or contaminated surfaces. Failure to adhere to IPAC protocols can lead to serious patient safety issues, including increased infection rates in immunocompromised patients who are at heightened risk for systemic complications. Continued education, vigilant practice, and a culture of accountability are essential to uphold these standards and ensure patient and staff safety.
Overall, your discussion provides a well-rounded view of the challenges and consequences posed by lapses in IPAC practices during a VRE outbreak

[Ivy]

Thank you for sharing your self-reflection in your practice. This is one of the things I used to forget during my clinical placement. In improving my practice, I ensure to make it a habit to disinfect my equipment after every client encounter. If I don’t make it a habit, I’ll often forget. Proper equipment handling is essential in infection control. It is also imperative to have a refresher in IPAC regularly. Infection control and prevention are a shared responsibility in protecting each other (workers, clients, and families).

[Mebo]

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.

[Mae Anne Zyrene]

This situation clearly highlights the need for IPAC Guidelines in our career. I believe that yearly courses on IPAC measures would be beneficial for everyone to refresh their knowledge and understanding. Mistakes like the example you pointed out are one example of why we need refresher courses to maintain the knowledge and practices that are needed for a safer and healthier environment. Hopefully, everything turned out okay in your unit! Thanks for sharing!

[Juana]

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.

[Aleksandra]

Hi Juana,

Thank you for sharing your experience. It really shows how important it is to follow IPAC protocols at all times, especially during outbreaks like COVID-19. Entering a COVID-positive patient’s room without any PPE is a serious risk—not just for the nurse, but for every other patient and staff member in the unit. As you mentioned, even if the task seems quick or routine, skipping safety steps can lead to major consequences.

Your post is a strong reminder that healthcare workers must always be alert and careful, even during busy shifts or when feeling tired. It’s easy to get caught up in the rush, but infection prevention should never be ignored. One small mistake can cause an outbreak or force staff to isolate, which then affects the whole care team.

I agree that education and peer accountability are key. It’s not about blaming others—it’s about looking out for each other and our patients. Speaking up when something isn’t right shows leadership and care.

IPAC isn’t just a policy—it’s a daily practice that protects lives. Your example helps show why we all need to stay committed to it, every shift. Thank you for reminding us how much our actions matter.

[Mae Anne Zyrene]

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.

[Aleksandra]

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.

[Carolina]

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.

[Shiyu]

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.

[Najmo]

Hello Shiyu,

You have highlighted the spread of infection when healthcare professionals easily break one of the transmission modes, which allows the organism to exit its chain of infection. When nurses neglect hand hygiene, nurses can easily spread the infection everywhere, such as to the working desk, to the next room patient, and even to contaminate our uniforms, etc. Healthcare professionals can easily strengthen hand hygiene protocol and can simply break the chain of infection.

[Najmo]

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.

[Carolina]

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.

[Shiyu]

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.

[Gemma]

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.

[Ivy]

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.

[Mintesinot]

During one of my earlier clinical experiences, I saw a situation where a coworker accidentally did not follow important infection prevention and control (IPAC) rules. We were in a long-term care facility, and a nurse went into a resident’s room without cleaning her hands after taking off her gloves. She had just finished caring for a wound and was quickly called to help another resident. In her hurry, she took off her gloves but forgot to wash her hands before leaving the room.
While this might seem like a small mistake, it was actually very risky. The next resident she helped had a weak immune system, and even a short contact with unclean hands could have introduced harmful germs. This could lead to a healthcare-associated infection (HAI).
The possible negative effects in such situations can be serious. Not following IPAC rules—especially washing hands, which is one of the best ways to prevent spreading infections—can lead to illnesses like MRSA, C. difficile, or even the flu. For people who are already vulnerable, these infections can cause serious health problems, longer hospital stays, higher healthcare costs, and even death.
This experience taught me how important it is not to skip steps, even when we are busy. It reminded me that infection control practices are not just for personal safety—they are crucial to protect our clients and maintain high standards of care.

[Author]

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