Background Doffing protocols for personal protective equipment (PPE) are critical for keeping healthcare workers (HCWs) safe during care of patients with Ebola virus disease. We assessed the relationship between errors and self-contamination during doffing. Methods Eleven HCWs experienced with doffing Ebola-level PPE participated in simulations in which HCWs donned PPE marked with surrogate viruses (ɸ6 and MS2), completed a clinical task, and were assessed for contamination after doffing. Simulations were video recorded, and a failure modes and effects analysis and fault tree analyses were performed to identify errors during doffing, quantify their risk (risk index), and predict contamination data. Results Fifty-one types of errors were identified, many having the potential to spread contamination. Hand hygiene and removing the powered air purifying respirator (PAPR) hood had the highest total risk indexes (111 and 70, respectively) and number of types of errors (9 and 13, respectively). ɸ6 was detected on 10% of scrubs and the fault tree predicted a 10.4% contamination rate, likely occurring when the PAPR hood inadvertently contacted scrubs during removal. MS2 was detected on 10% of hands, 20% of scrubs, and 70% of inner gloves and the predicted rates were 7.3%, 19.4%, 73.4%, respectively. Fault trees for MS2 and ɸ6 contamination suggested similar pathways. Conclusions Ebola-level PPE can both protect and put HCWs at risk for self-contamination throughout the doffing process, even among experienced HCWs doffing with a trained observer. Human factors methodologies can identify error-prone steps, delineate the relationship between errors and self-contamination, and suggest remediation strategies.

中文翻译：

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人为因素风险分析埃博拉级别个人防护设备的脱气协议：将错误映射到污染。

背景个人防护设备（PPE）的脱胶协议对于在医护埃博拉病毒病患者期间确保医护人员（HCW）安全至关重要。我们评估了落纱过程中错误与自我污染之间的关系。方法11名接受落棉埃博拉病毒防护用品的HCW参加了模拟，其中HCW佩戴了标有替代病毒（ɸ6和MS2）的PPE，完成了临床任务，并在落纱后进行了污染评估。对模拟进行了视频记录，并进行了故障模式和影响分析以及故障树分析，以识别落纱过程中的错误，量化其风险（风险指数）并预测污染数据。结果确定了51种错误，许多错误都有可能扩散污染。手卫生和拆卸动力空气净化呼吸器（PAPR）罩的总危险指数最高（分别为111和70）和错误类型数量（分别为9和13）。在10％的灌木丛上检测到ɸ6，并且故障树预测污染率为10.4％，这很可能是在拆卸期间PAPR罩无意中接触到灌木丛时发生的。在10％的手，20％的磨砂膏和70％的内手套中检出了MS2，预计检出率分别为7.3％，19.4％，73.4％。MS2和ɸ6污染的故障树表明了相似的途径。结论埃博拉水平的个人防护装备既可以保护并防止医务工作者在整个落纱过程中遭受自我污染的危险，即使是经验丰富的医务工作者在训练有素的观察员进行落纱的情况下也是如此。人为因素方法论可以识别容易出错的步骤，