Process Failures That Increase the Risk of Infection Through Respiratory Droplets: A Study of Patient Safety Events Reported by Hospitals Across Pennsylvania

Respiratory pathogens can lead to pneumonia, bronchiolitis, and death. Rapid identification, along with appropriate standard and isolation precautions, are necessary to prevent the spread of infectious agents causing respiratory infections. We analyzed patient safety events reported to the Pennsylvania Patient Safety Reporting System that were related to viruses and bacteria spread through respiratory droplets. An analysis of events that occurred from January 1, 2019, through December 31, 2019, led to the identification of 338 events involving process failures related to recognizing infectious agents that are spread through respiratory droplets, implementing measures to prevent their spread, or providing timely treatment. Detailed analysis of the process failures showed that 54.9% were associated with processes in testing or processing of laboratory specimens; 29.7% were associated with isolation-related procedures; and 15.4% were associated with medications, triage/assessment, documentation/verbal communication, or not providing the standard of care for patients in missed/delayed orders, procedures, or referrals. Implementation of risk-reduction strategies can help to further reduce the spread of pathogens through respiratory droplets in the hospital setting and further enhance patient safety. These strategies include evaluating collection processes for testing/laboratory specimens, consistently using empiric isolation precautions based on initial triage and patient presentation, and evaluating processes for admissions and transfers.