[John-paul]

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):

[Ibikemi]

A colleague, PSW, attended to a resident with emesis, came out together from the room, I went straight to the washroom to wash my hands, and she went to another room after doffing the PPE without washing her hands and said the call bell is escalating, “I need to quickly attend to the resident before the calls get to management.” I told her the importance of hand washing, but she dashed to the room and attended to the resident. When I resumed the following night, I learnt the resident had been sent to the hospital due to emesis 3X with diarrhea.
I reported to my DOW, and she organized an in-house workshop on handwashing.

[Rachel]

Hi Ibikemi, by washing your hands after doffing PPE you demonstrated # 3 of the CNO’s Code of Conduct “Nurses provide safe and competent care”, you were providing safe and competent care by killing any potential microbes on your hands by killing them when you washed your hands after doffing all PPE to minimize the potential for them to spread to the next resident you come into contact with ensuring resident safety. It was also the right thing to report this to your manager as they were able to provide helpful education to staff, reminding everyone on the importance of hand hygiene, so that another preventable incident like that does not happen again.

[Diane]

Hello, I noticed PSW and nurses wearing two pairs of gloves, they kept one pair on the whole time providing care only replacing top pair noted did not wash hands or even apply ABHS. I do remember approaching and explaining this was not best practice and also infection control IPAC , they were the same people who consistently wears 2 masks while entering and exiting clients rooms, after discussion with IPAC lead, new education/ review of policies were reviewed by all staff.

[Adeyemi]

A PSW went into a resident’s room to feed the resident and washed her hands upon entry before resident contact but when she left the the room she did not wash her hands when she left the room. This action had the potential of transmitting microbes from this resident to to other residents with whom she subsequently came in contact with thereby causing healthcare associated infections.

[Amanda]

During an outbreak, both nurses and PSWs were seen entering isolated rooms. They had donned PPE prior to entering one room. However, when leaving the first room, they removed only their gloves, applied a new pair and entered another isolated room in the same PPE. Staff did not remove their their gown, mask or eye wear. They also did not perform hand hygiene. This placed several residents at risk for infection and extending the outbreak. Health teaching was provided by IPAC staff, including proper hand hygiene and donning and doffing PPE.

[Rachel]

I was completing a hand hygiene audit during lunch. During this audit I observed that after coming into contact with a resident the RPN went back to the med cart and did not complete proper hand hygiene and they began to prepare the next residents medications. I immediately reminded the RPN to preform hand hygiene after this point of contact and provided education that they need to preform hand hygiene after any point of contact and informed them that we do this to prevent the spread of microbes. I made a note of the misstep in the audit which than alerts the IPAC manager of the missing step. By forgetting to preform hand hygiene after coming into contact with a resident they could be spreading microbes to the next resident they come into contact with as the potential germs and bacteria on their hands will be touching the medication cup which the next resident will come into contact with.

[danait]

While supervising a student during medication administration, we had several patients on contact precautions. Although the student recognized the requirement for PPE based on the isolation signage posted at the room entrance, they demonstrated inadequate knowledge of proper donning and doffing technique. Upon exiting one patient’s room, the student proceeded into the hallway wearing the same isolation gown and attempted to enter another patient’s room. Immediate intervention was provided ,including a review of appropriate PPE use, correct donning and doffing techniques, and proper hand hygiene practice. The four moments of hand hygiene education was reinforced and the importance of hand washing in preventing cross-contamination. The student was able to demonstrate the correct use of PPE and adherence to IPAC protocols and minimizing the transmission of infectious organisms.

[Alexandra]

While still working as a PSW in long term care I observed many people remembering to use gloves and hand sanitizer before and after completing care however I would rarely see anybody actually wash their hands with soap and water. This means that there could be an increased risk of transmitting those organisms not killed by alcohol. These infections have the potential to spread very quickly in a long term care setting.

[Kimberly]

I have also observed staff not hand washing. While gloves and hand sanitizer are used lots, the lack of proper hand washing with soap and water will definitely increase the risk of spreading organisms that alcohol dose not eliminate, especially In a LTC facility in such a venerable setting with potential for infections so spread quickly.

[Rachel]

Hand sanitizer only goes so far especially if its not being used correctly. I remember a staff member asking me why I chose to wash my hands over using hand sanitizer having them state ” its faster to use the hand sanitizer” I had to explain to them that its NOT and I educated them that you rub your hands for the same amount of time with hand sanitizer as you would with washing your hands. Staff need to ensure that they are covering every spot on their hands and doing so for a full 20 seconds before moving on otherwise your not killing all the bacteria on your hands resulting in spreading the organism.

[Margaret]

You make an excellent point about the limitations of alcohol-based hand sanitizer, especially since it is not effective against organisms like C. difficile that require soap and water for proper removal. In a long-term care setting where residents are highly vulnerable, consistent and proper handwashing practices are critical to preventing rapid infection spread.

[danait]

That’s an important observation. Nursing and PSW staff often delay hand hygiene until their hands feel sticky or visibly soiled, particularly during the busiest parts of their shifts. This may help explain the increase in infections among patients and residents resulting from transmission by staff, including nosocomial or hospital-acquired infections.

[Kimberly]

In a hospital setting, observed a student donning PPE, all steps where taken correctly. Few moments later student had exited the room to get supplies with the PPE still donned. I had then stopped the student and provided health teaching in the importance of doffing PPE when exiting isolated area, and how it can spread infection to other staff member and or patient’s, potentially causing outbreak, hospital inquired infection, etc. The student then demonstrated correct practice of donning and doffing PPE and knowledge of infection prevention.

[Munazzah]

As a nurse, I recognize the importance of patient safety and teaching as part of nursing care. The above experience reinforced the importance of timely intervention, education, and role modeling to maintaining patient safety and infection prevention standards. I would also advocate for ongoing education and application of IPAC standards to support safety and accountability within the healthcare team.

[Sheila]

A situation I witnessed during clinical placement involved a colleague who briefly entered a client’s room without performing hand hygiene after completing wound care for one client and proceeded to assist another with feeding, assuming their hands were still clean because they had worn gloves.
Although no immediate harm occurred, the potential negative outcomes were significant. Without proper hand hygiene, microorganisms can easily transfer from one client to another. This could lead to healthcare-associated infections (HAIs). It also increases the risk of cross-contamination on high-touch surfaces, potentially exposing staff and other clients.
This situation reinforced the importance of consistently following IPAC practices, particularly the 4 Moments of Hand Hygiene, to protect both clients and healthcare workers.

[Munazzah]

As a nurse, I understand that hand hygiene is fundamental to safe and ethical nursing practice. In the above-mentioned event, the failure to perform hand hygiene between patient interaction (even though gloves were used) posed a potential negative outcome for the patient due to transfer of microorganism potentially leading to infection. Proper hand hygiene must take place before and after every interaction with patient. As a nurse, I have a duty to protect my patient from any kind of potential harm.

[Munazzah]

While I was at my clinical placement, I noticed a colleague who did not perform hand hygiene during mealtime between residents while feeding. They forgot it because they had to grab some cutlery for the resident. However, this is not in line with IPAC practices. The potential negative outcomes for residents, related to not following the appropriate IPAC practices, were significant as it compromises resident’s safety and well being especially those with weakened immune system. Reflecting on this event is a reminder to myself to remember to follow IPAC guidelines even in busy and stressful times to protect myself and residents.

[Sheila]

Thank you for sharing this experience, Munazzah. It’s a great reminder of how easily IPAC steps, especially hand hygiene, can be overlooked during busy moments, even with good intentions. As you pointed out, skipping hand hygiene between residents can put those with weakened immune systems at real risk. Your reflection shows strong awareness and accountability, and it reinforces the importance of slowing down enough to follow IPAC practices consistently to protect everyone’s safety.

[Tracey]

One evening shift about 8 pm I was conducting med pass to residents in their room. Our facility was experiencing an influenza outbreak and we were short staffed. Previously at shift change, and our routine huddle I emphasized to staff the importance of donning and doffing PPE and following our home policy and procedure guidelines on infection control. During med pass I witnessed a PSW doffing her PPE but not using the supplied hand sanitizer before entering another resident’s room. From the doorway I reminded the PSW of her responsibility to follow the signage posted to follow directions. The PSW apologized, then followed the correct protocols. The PSW explained she had forgotten because she was so busy with short staff and another staff on break. I listened and acknowledged what she said and reported that I was available to assist if needed. Later, I reported to the IPAC nurse my staff would benefit from a discussion re: the importance of hand hygiene

[Katrine]

During my training as a visiting nurse, I observed my preceptor performing wound care without wearing gloves. She explained that ”back in her time” gloves weren’t commonly used, and although she washed her hands, she never wore gloves. Not following IPAC practices like wearing gloves could increase the risk of transmitting bacteria or viruses to the client, potentially leading to infection or delayed healing. Observing this emphasized for me the importance of always following current IPAC standards, even if someone experienced does it differently.

[Amanda]

This happens in my facility as well with some of the senior staff. They perform incontinent care on residents without wearing gloves, then only use ABHS to “clean” their hands after resident care. They needed to be reminded of proper use of PPE and hand hygiene. Management had the health unit come in to provide an in service on hang hygiene.

[Monica]

Hi Katrine…
In response to your submission. I too recall when a co-worker did not don gloves, she was a ‘seasoned experienced’ nurse who also expressed similar statements as to how things were done ‘in her day’.(it was not a community setting, but on a hospital unit).
I remember explaining to her that in her day we didn’t have the ‘super bugs’, that are prevalent now.. plus providing pericare on one person and then moving on to the next person, was highly risky, (aside from being gross). I asked her if she would like to be the second patient receiving care when her nurse didn’t wear gloves…. I wasn’t trying to be unkind, just trying to get my point across. Eventually, the Unit Manager provided 1:1 education to the nurse (and to the unit in general.. as a ‘refresher’).

[Ibikemi]

Hi Amanda,
This is a concern when talking about IPAC in any facility, especially during an outbreak. Entering Isolation rooms without properly doffing PPE and performing hand hygiene increases the risk of cross-contamination and outbreak spread.
Changing gloves alone is not sufficient; ongoing education and reinforcement by IPAC staff are essential to ensure resident safety.

[Svetlana]

I am strongly agree with Amanda’s’ statement. As a nurse in long-term facility, I understand that failure to follow IPAC practices can result in increased infections, outbreaks, hospitalizations, decline in resident health, emotional distress, reduced quality of life, and increased risk of death. In our facility during outbreaks IPAC team are increasing audit for proper donning and doffing PPE practice, including hand washing. Continuously providing healthy guidance for staff and visitors.

[Monica]

Hello All…
Apologies to all, as have not responded to modules as I should have… (++ circumstances at work)..
An example I can recall is when a nurse colleague did not follow proper hand hygiene procedures was a fellow registered staff member ‘double gloving’ when entering a room, and removing the top glove, and then using the hand sanitizer before donning a new ‘top glove’.
Hand Hygiene and IPAC practices were reviewed with him, but he basically ‘blew us off’, and continued with this practice.
We were working in a LTC wing of a local hospital, and i think that he felt it wasn’t necessary to follow safe IPAC practices, genuinely believing that he was practicing safe HH (because he was using a double glove technique).
It took a couple of reminders and then finally a report to the unit manager to have a talk with him and to clarify the expectations . His behaviour changed and he then began to follow IPAC practices successfully.

[Monica]

Hi again..
To further answer my own submission, the negative outcome of not following hand hygiene practices is that he could have spread infection to other residents each time we provided peri care and brief change. Not to mention contaminating any surfaces that he touched. I think he genuinely believed that by wearing 2 gloves he was protecting himself (and the residents), and was trying to save steps.. I think that the visit to the Unit Manager’s office changed his thought process as he began to follow the protocols.

[Margaret]

In the community setting, I have seen situations where IPAC practices were not fully followed due to time pressures—for example, a colleague not performing proper hand hygiene between client visits or reusing PPE longer than recommended. While this may seem minor, it can lead to significant negative outcomes such as the transmission of infections between vulnerable clients, delayed healing, increased hospitalizations, and loss of client trust. In community care, where clients often have complex health needs, strict adherence to IPAC practices is essential to protect both clients and healthcare providers.

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