n engl j med 355;2 www.nejm.org july 13, 2006 PERSPECTIVE 121 System Failure versus Personal Accountability — The Case for Clean Hands Donald Goldmann, M.D. transmission of mycobacterium tuberculosis from health care workers Jensen PA, Lambert LA, Iademarco MF, Ridzon R. Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care settings, 2005. MMWR Re- comm Rep 2005;54:1-141. Salazar-Schicchi J, Jedlovsky V, Ajayi A, 3. 4. Colson PW, Hirsch-Moverman Y, El-Sadr W. Physician attitudes regarding bacille Calmette- Guerin vaccination and treatment of latent tuberculosis infection. Int J Tuberc Lung Dis 2004;8:1443-7. Mazurek GH, Jereb J, Lobue P, Iademarco 5. MF, Metchock B, Vernon A. Guidelines for using the QuantiFERON-TB Gold test for de- tecting Mycobacterium tuberculosis infec- tion, United States. MMWR Recomm Rep 2005;54(RR-15):49-55. [Erratum, MMWR Morb Mortal Wkly Rep 2005;54:1288.] 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 cou- ple 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 care- givers to wash their hands, but only after witnessing repeated fail- ures does she muster the courage to speak up about the practice she thought would be routine. By then, her baby has acquired methicil- lin-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 even- tually proves fatal. Such prevent- able infections, caused by the fail- ure to practice hand hygiene, are far from rare, and they occur in many of the finest neonatal in- tensive care units in the United States. MRSA and other health care– associated infections have been prime targets of hospital infec- tion-control and patient-safety pro- grams for years, yet the prevalence of antibiotic-resistant bacteria con- tinues 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 under- mine the best efforts of well- intentioned, highly motivated clinicians and health care per- sonnel to provide safe care. A ma- jor 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 sys- tems rather than blaming people who make mistakes is critical, since it encourages caregivers to report adverse events and near misses that might be prevent- able in the future. Improvement is impossible without such re- ports, 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 infre- quently, lower-profile mistakes that many caregivers make vir- tually every day, such as not wash- ing 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 hold- ing individual providers account- able for their everyday practices. Curbing the alarming increase in the rate of antibiotic-resistant infections surely requires both systemic improvements and in- creased personal accountability. Infections with antibiotic-resis- tant bacteria such as MRSA, which are difficult to treat, are trans- mitted primarily by the contami- nated hands of health care provid- ers who have touched a colonized patient or something in the pa- tient’s environment. Patients who are colonized or infected with resistant pathogens often have billions of colony-forming units of bacteria per milliliter of spu- tum or per gram of stool. Their skin and immediate environment may also be heavily contaminat- Copyright © 2006 Massachusetts Medical Society. All rights reserved. Downloaded from www.nejm.org on July 21, 2006 . For personal use only. No other uses without permission.