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System Failure versus Personal Accountability
- The Case for Clean Hands

Donald Goldmann, M.D.

A new mother sits by her tiny, premature baby in a neonatal intensive care unit. She watches as a physician
touches the baby without first washing his hands or using the waterless, alcohol-based hand antiseptic just
a couple of feet away. A few minutes later, a nurse and then another doctor also fail to perform these basic
procedures. When her baby was admitted to the unit, the mother was told to remind caregivers to wash their
hands, but only after witnessing repeated failures does she muster the courage to speak up about the practice
she thought would be routine. By then, her baby has acquired methicillin-resistant Staphylococcus aureus (MRSA)
— probably transported on the hands of a caregiver who had been examining other babies who are colonized with
MRSA. A few days later, MRSA invades the baby's bloodstream; it eventually proves fatal. Such preventable
infections, caused by the failure to practice hand hygiene, are far from rare, and they occur in many of the
finest neonatal intensive care units in the United States.

MRSA and other health care–associated infections have been prime targets of hospital infection-control and
patient-safety programs for years, yet the prevalence of antibiotic-resistant bacteria continues to increase,
and the rate of infections caused by these pathogens remains unacceptable. What can be done about these seemingly
intractable problems?

Patient-safety experts stress that complex, error-prone systems are at the root of most mistakes in health
care. Archaic, poorly designed systems often undermine the best efforts of well-intentioned, highly motivated
clinicians and health care personnel to provide safe care. A major goal of contemporary patient-safety programs
is to encourage a culture of safety and create a blame-free environment in which errors are seen as a by-product
of bad systems, not as caused by bad or incompetent people. This orientation toward improving systems rather
than blaming people who make mistakes is critical, since it encourages caregivers to report adverse events and
near misses that might be preventable in the future. Improvement is impossible without such reports, which permit
hospitals to gain an understanding of the factors that lead to mistakes and create systems that support safer
practices. Although reports tend to focus on major, dangerous errors that occur relatively infrequently,
lower-profile mistakes that many caregivers make virtually every day, such as not washing their hands, also need
to be documented and understood if the systems are to be improved.

But if we really are serious about making care safer, I would argue that we need to find the right balance between
blaming mistakes on systems and holding individual providers accountable for their everyday practices. Curbing the
alarming increase in the rate of antibiotic-resistant infections surely requires both systemic improvements and
increased personal accountability. Infections with antibiotic-resistant bacteria such as MRSA, which are
difficult to treat, are transmitted primarily by the contaminated hands of health care providers who have touched a
colonized patient or something in the patient's environment. Patients who are colonized or infected with resistant
pathogens often have billions of colony- forming units of bacteria per milliliter of sputum or per gram of stool.
Their skin and immediate environment may also be heavily contaminated. Caregivers who leave the bedsides of such
patients without performing hand hygiene may carry thousands or even hundreds of thousands of colony-forming units
of antibiotic-resistant bacteria on their hands. Even if the caregivers wear gloves while caring for patients who
they know are colonized with resistant bacteria, they frequently contaminate their hands when they remove their
gloves.

Fortunately, the remedy for this situation is simple. If every caregiver would reliably practice simple hand hygiene
when leaving the bedside of every patient and before touching the next patient, there would be an immediate and
profound reduction in the spread of resistant bacteria. The recent widespread deployment of waterless, alcohol-based
hand antiseptics has made this task easier even for harried caregivers. Performing hand hygiene with these products
kills bacteria (with the exception of Clostridium difficile) very rapidly, takes much less time than traditional
hand washing, and is gentler on the hands than the repeated use of soap and water. Yet compliance with hand hygiene
remains poor in most institutions — often in the range of 40 to 50 percent.1,2

The system is partly to blame. First, staff members must not be so seriously overworked that they do not have time to
perform important standard procedures. Second, many hospitals do not have programs to ensure that caregivers are
adequately educated — that they know exactly how much alcohol to apply, how long to rub their hands together, and
which skin surfaces are most important to cover. Once educated, caregivers should also have their hand-hygiene
competency assessed and certified. And then they must have reliable access to alcohol-based antiseptics at the point
of care, which requires a foolproof system for refilling dispensers before they have run dry. Dispensers must be
functional and must reliably deliver the appropriate amount of alcohol. Although the alcohol-based rubs in current
use are gentle on the hands, lotions should also be easily accessible, in case of irritation. Clearly, the resolution
of such system issues is not terribly complicated; in the realm of hand hygiene, near-perfect reliability should be
achievable.3,4,5

Imagine, then, a hospital that has perfected its hand-hygiene system and monitors it regularly to detect failures. If a
caregiver in such an institution neglects to perform hand hygiene when leaving the bedside in any case except a life-
threatening emergency, it is no longer logical to blame the system. Experts in human error have a word for the failure
to follow clear rules in the face of well- functioning systems: "violation." Repeated violations in health care,
as in any industry, should have consequences.

Another industry in which cleanliness is paramount — computer-chip manufacturing — may be able to teach us something
about this issue. When a worker enters a "clean room" where computer chips are being made, he or she must don a special
suit, gloves, and mask to prevent the chips from becoming contaminated. These required materials are always available,
and the clean-room system is highly reliable. A single failure to follow the rules results in a warning. Employees
who violate the rules twice risk disciplinary action — for, after all, millions of dollars are at stake if contamination
occurs. The performance expectations, in my view, should be at least as high when the stakes are lives rather than
profits.

When a doctor or nurse can reduce the spread of antibiotic-resistant bacteria by practicing simple hand hygiene,
accountability should  matter. True, the hospital and its leaders are accountable for establishing a system in which
caregivers have the knowledge, competence, time, and tools to practice perfect hygiene. But each caregiver has the
duty to perform hand hygiene — perfectly and every time. When this widely accepted, straightforward standard of care
is violated, we cannot continue to blame the system.