OBJECTIVE To systematically assess safety risks pertaining to tracheostomy care in the long-term care (LTC) setting using a human factors engineering approach. DESIGN We utilized a 5-part approach to complete our proactive risk assessment: (1) performed a hierarchical task analysis of the processes of tracheostomy stoma and suctioning; (2) identified failure modes where a subtask may be completed inappropriately; (3) prioritized each failure mode based on a risk priority scale; (4) identified contributing factors to and consequences for each of the prioritized failure modes; and (5) identified potential solutions to eliminate or mitigate risks. SETTING Three high-acuity LTC facilities with ventilator units across Maryland. METHODS The hierarchical task analysis was conducted jointly by 2 human-factors experts and an infectious disease physician based on respiratory care policies from the Centers for Disease Control and Prevention and existing policies at each LTC facility. The findings were used to guide direct observations with contextual inquiry and focus group sessions to assess safety risks for residents receiving tracheostomy care. RESULTS Direct observations of tracheostomy care and suctioning in the LTC setting revealed significant variations in practice. Respiratory therapists working in LTC reported lack of training and ambiguity concerning recommended procedures to reduce infection transmission in daily care. Highest risk steps identified in tracheostomy care and suctioning included hand hygiene, donning gloves, and providing intermittent suctioning as the suction catheter was withdrawn. Participants identified risk mitigation strategies targeting these high-risk failure modes that addressed contributing factors related to 5 work system components: person (knowledge and competency), task (eg, urgency or time constraints), tools and technology (eg, availability of hand sanitizer), environment (eg, communal rooms), and organization (eg, patient safety culture). CONCLUSIONS AND IMPLICATIONS Human factors analysis of the highest-risk steps in respiratory care activities in the LTC setting suggest several potential mitigation strategies to decrease the risk of infection transmission. Clear procedure guidelines with training are needed to reduce ambiguity and improve care in this setting. Involving frontline staff in patient safety issues using human factors principles and risk analysis may encourage participation and improve the infection prevention culture in LTC.

中文翻译：

---

长期护理环境中的呼吸实践：基于人为因素的风险分析

目的 使用人因工程方法系统地评估与长期护理 (LTC) 环境中气管切开术护理相关的安全风险。设计 我们采用 5 部分方法来完成我们的主动风险评估：（1）对气管造口和抽吸过程进行分层任务分析；(2) 识别出子任务可能无法正确完成的故障模式；(3) 根据风险优先级等级划分每种故障模式的优先级；(4) 确定每个优先故障模式的影响因素和后果；(5) 确定消除或减轻风险的潜在解决方案。设置 在马里兰州设有三个配备呼吸机装置的高敏 LTC 设施。方法 分层任务分析由 2 位人为因素专家和一位传染病医生根据疾病控制和预防中心的呼吸护理政策和每个 LTC 设施的现有政策共同进行。调查结果用于指导直接观察，包括背景调查和焦点小组会议，以评估接受气管造口术护理的居民的安全风险。结果 在 LTC 环境中对气管切开术护理和抽吸的直接观察揭示了实践中的显着差异。在 LTC 工作的呼吸治疗师报告说，在日常护理中减少感染传播的推荐程序缺乏培训和模棱两可。在气管切开术护理和抽吸中确定的最高风险步骤包括手部卫生、戴手套、并在抽吸导管拔出时提供间歇抽吸。参与者确定了针对这些高风险故障模式的风险缓解策略，这些策略解决了与 5 个工作系统组件相关的促成因素：人员（知识和能力）、任务（例如紧迫性或时间限制）、工具和技术（例如洗手液的可用性） )、环境（例如，公共房间）和组织（例如，患者安全文化）。结论和意义 LTC 环境中呼吸护理活动中风险最高的步骤的人为因素分析提出了几种潜在的缓解策略，以降低感染传播的风险。需要经过培训的明确程序指南，以减少歧义并改善这种情况下的护理。