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


  • Amy Harper, PhD, RN Patient Safety Authority
  • Elizabeth Kukielka, PharmD, MA, RPH Patient Safety Authority
  • Rebecca Jones, MBA, RN Patient Safety Authority



respiratory, pneumonia, isolation, droplet precautions, influenza, syncytial


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.

Author Biographies

Amy Harper, PhD, RN, Patient Safety Authority

Amy Harper ( is an infection prevention analyst for the Patient Safety Authority. She is board certified in medical-surgical nursing (CMSRN) and in infection control and epidemiology (CIC), and is a member of the Association for Professionals in Infection Control and Epidemiology (APIC).

Elizabeth Kukielka, PharmD, MA, RPH, Patient Safety Authority

Elizabeth Kukielka is a patient safety analyst on the Data Science and Research team at the Patient Safety Authority. Before joining the PSA, she was a promotional medical writer for numerous publications, including Pharmacy Times and The American Journal of Managed Care. Kukielka also worked for a decade as a community pharmacist and pharmacy manager, with expertise in immunization delivery, diabetes management, medication therapy management, and pharmacy compounding.

Rebecca Jones, MBA, RN, Patient Safety Authority

Rebecca Jones is director of Data Science and Research at the Patient Safety Authority, where she also founded and serves as director of the Center of Excellence for Improving Diagnosis. Her previous roles at the PSA include director of Innovation and Strategic Partnerships, and regional patient safety liaison. Before joining the PSA, Jones served in various roles leading patient safety efforts and proactively managing risk in healthcare organizations. She currently is chair of the Practice Committee of the Society to Improve Diagnosis in Medicine and serves on the Advisory Committee of the Coalition to Improve Diagnosis.


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How to Cite

Harper, A. ., Kukielka, E., & Jones, R. . (2020). Process Failures That Increase the Risk of Infection Through Respiratory Droplets: A Study of Patient Safety Events Reported by Hospitals Across Pennsylvania. Patient Safety, 2(3), 10–23.



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