Using medical student observers of infection prevention, hand hygiene, and injection safety in outpatient settings: A cross-sectional survey

Published:January 21, 2016DOI:


      • Self-report and behavior observation should both be part of infection prevention assessments.
      • Outpatient attention is needed on infection prevention, hand hygiene, and injection safety.
      • Medical students can identify and share quality improvement opportunities during rotations.
      • Public health and medical practice collaboration can enhance healthcare provider education.


      Health care-associated infection outbreaks have occurred in outpatient settings due to lapses in infection prevention. However, little is known about the overall infection prevention status in outpatient environments.


      A cross-sectional design was employed to assess infection prevention policies and practices at 15 outpatient sites across New Mexico in 2014 during a medical student outpatient rotation. A standardized infection prevention checklist was completed via staff interview; observations of injection safety practices and hand hygiene behavior were conducted. Aggregate data were analyzed using Excel (Microsoft, Redmond, WA) and Stata (version 12.1, Stata Corp, College Station, TX) statistical software.


      Medical practice staff interviews reported a mean of 92.8% (median, 96.7%; range, 75.0%-98.9%) presence of recommended policies and practices. One hundred sixty-three injection safety observations were performed that revealed medication vial rubber septums were disinfected with alcohol 78.4% (95% confidence interval [CI], 71.1%-84.7%) of the time before piercing. Three hundred thirty hand hygiene observations revealed 33.9% (95% CI, 28.8%-39.1%) use of alcohol-based handrub, 29.1% (95% CI, 24.2%-34.0%) use of soap and water, and 37.0% (95% CI, 31.8%-42.4%) use of no hand hygiene.

      Discussion and Conclusion

      These findings support the need for ongoing infection prevention quality improvement initiatives in outpatient settings and underscore the importance of assessing both self-report and observed behavior of infection prevention compliance.

      Key Words

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        • Centers for Disease Control and Prevention
        Guide to infection prevention for outpatient settings: minimum expectations for safe care.
        (Available from:) (Accessed October 12, 2014)
        • Jarvis W.R.
        Infection control and changing health-care delivery systems.
        Emerg Infect Dis. 2001; 7: 170-173
        • Williams I.T.
        • Perz J.F.
        • Bell B.P.
        Viral hepatitis transmission in ambulatory health care settings.
        Clin Infect Dis. 2014; 38: 1592-1598
        • Thompson N.D.
        • Perz J.F.
        • Moorman A.C.
        • Holmberg S.D.
        Nonhospital Health Care-Associated Hepatitis B and C Virus Transmission: United States, 1998-2008.
        Ann Intern Med. 2009; 150: 33-39
        • Greeley R.D.
        • Semple S.
        • Thompson N.D.
        • High P.
        • Rudowski E.
        • Handschur E.
        • et al.
        Hepatitis B outbreak associated with a hematology-oncology office practice in New Jersey, 2009.
        Am J Infect Control. 2011; 39: 663-670
        • Cohen A.L.
        • Ridpath A.
        • Noble-Wang J.
        • Jensen B.
        • Peterson A.M.
        • Arduino M.
        • et al.
        Outbreak of Serratia marcescens bloodstream and central nervous system infections after interventional pain management procedures.
        Clin J Pain. 2008; 24: 374-380
        • Centers for Disease Control and Prevention
        One and Only Campaign injection safety checklist.
        (Available from:) (Accessed October 12, 2014)
        • World Health Organization
        Observation form, revised August 2009.
        (Available from:) (Accessed June 21, 2013)
        • Hopkins J.
        Medicine. Hand hygiene observation tool.
        (Available from:) (Accessed June 21, 2013)
        • Centers for Disease Control and Prevention
        Transmission of hepatitis B virus among persons undergoing blood glucose monitoring in long-term-care facilities—Mississippi, North Carolina, and Los Angeles County, California, 2003-2004.
        MMWR Morb Mortal Wkly Rep. 2005; 54: 220-223
        • Samandari T.
        • Malakmadze N.
        • Balter S.
        • Perz J.F.
        • Khristova M.
        • Swetnam L.
        • et al.
        A large outbreak of hepatitis B virus infections associated with frequent injections at a physician's office.
        Infect Control Hosp Epidemiol. 2005; 26: 745-750
        • Centers for Disease Control and Prevention
        One and Only Campaign frequently asked questions regarding safe practices for medical injections.
        (Available from:) (Accessed October 13, 2014)
        • Gounder P.
        • Beers R.
        • Bornschlegel K.
        • Hinterland K.
        • Balter S.
        Medication injection safety knowledge and practices among anesthesiologists: New York State, 2011.
        J Clin Anesth. 2013; 25: 521-528
        • Walker J.L.
        • Sistrunk W.W.
        • Higginbotham M.A.
        • Burks K.
        • Halford L.
        • Goddard L.
        • et al.
        Hospital hand hygiene compliance improves with increased monitoring and immediate feedback.
        Am J Infect Control. 2014; 42: 1074-1078
        • Mensah E.
        • Murdoch I.E.
        • Binstead K.
        • Rotheram C.
        • Franks W.
        Hand hygiene in routine glaucoma clinics.
        Br J Opthamol. 2005; 89: 1541-1542
        • Kukanich K.S.
        • Kaur R.
        • Freeman L.C.
        • Powell D.A.
        Evaluation of a hand hygiene campaign in outpatient health care clinics.
        Am J Nurs. 2013; 113: 36-42
        • Allegranzi B.
        • Sax H.
        • Pittet D.
        Hand hygiene and healthcare system change within multi-modal promotion: a narrative review.
        J Hosp Infect. 2013; 83: S3-10
        • Pittet D.
        Improving adherence to hand hygiene practice: a multidisciplinary approach.
        Emerg Infect Dis. 2001; 7: 234-240
        • Blasiak R.C.
        • Stokes C.L.
        • Meyerhoff K.L.
        • Hines R.E.
        • Wilson L.A.
        • Viera A.J.
        A cross-sectional study of medical students' knowledge of patient safety and quality improvement.
        N C Med J. 2014; 75: 15-20
        • Levitt D.S.
        • Hauer K.E.
        • Poncelet A.
        • Mookherjee S.
        An innovative quality improvement curriculum for third-year medical students.
        Med Educ Online. 2012; 17: 18391