Respiratory Practices in the Long-term Care Setting: A Human Factors–Based Risk Analysis

Morgan J. Katz, Patience M. Osei, Arjun Vignesh, Andrea Montalvo, Ifeoluwa Oresanwo, Ayse P. Gurses

Research output: Contribution to journalArticlepeer-review


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and suctioning included hand hygiene, donning gloves, and providing intermittent suctioning as the suction catheter was withdrawn.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.

Original languageEnglish (US)
Pages (from-to)1134-1140
Number of pages7
JournalJournal of the American Medical Directors Association
Issue number8
StatePublished - Aug 2020


  • Respiratory care
  • human factors
  • infection prevention
  • long-term care
  • system analysis

ASJC Scopus subject areas

  • Nursing(all)
  • Health Policy
  • Geriatrics and Gerontology


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