Hospital Care '3,000 Times Less Safe Than Air Travel,' Says TJC Chief

For example, he said, in an experiment with hand hygiene compliance at eight hospitals, experts realized there were 10 very different reasons for non-compliance, and those reasons varied at each facility.

At one hospital, the sinks and hand gel dispensers were in inconvenient locations. At another, there was no convenient place for workers to put down their items while they wash.

At another hospital, the safety culture did not stress hand hygiene at all levels.  At another, there was the incorrect perception that hand hygiene is not needed if gloves are worn. At another, workers frequently simply forget to wash their hands. And so on.

When hospitals realize that they must individualize their own process obstacles, and work from there, they can move forward to that progressively less-elusive goal: higher reliability, Chassin said.

At the end of any given day, a conscientious person looks back to assess what went well, and what didn't. And of course, there are excuses and rationalizations. I know I do.

I forgot. Didn't know. Got distracted. Misinterpreted. Presumed. Or, I just wasn't concentrating.

In healthcare, however, we have to find ways to check those errors, and make it easier to prevent than to cause them.