Error Proofing Handwashing?


Hand washing and proper hand hygiene is a big concern at most hospitals — thankfully so, since hand hygiene and other basic infection control measures can save lives, preventing or slowing the spread of harmful bugs like MRSA and C-Diff, bugs that can be acquired during a hospital stay.

This article talks about how MRSA cases have been reduced in ICU's through better prevention.

“The risk of bloodstream infections caused by MRSA that are associated with the use of central line catheters has dramatically declined by 50 to 70 percent since 2001, in all types of adult ICUs,” said lead researcher Dr. Deron C. Burton, associate director of CDC's Health Equity National Center for Health Marketing.

The drop in these infections is largely due to better procedures that have improved the safety of catheters, Burton said. “There has been improvement in the sterility of how they are inserted and how they are cared for while they are in the patient,” he explained.

This article talks about how soap and water can help slow c-diff. Basic “blocking and tackling”, eh? Getting 100% compliance with proper hand hygiene proves easier said than done, unfortunately. Hospitals often rely on signs that lecture, I mean remind, staff or rely on hospital visitors (or patients) to ask their caregivers if they've washed their hands. This can be an awkward exchange, on many levels, and many patients are afraid to speak up.

The basic Lean concept of Error Proofing is interesting to through around in this context. How CAN we error proof proper hand hygiene? We can do spot checks, but we can't watch people constantly, it seems. We can make it easy to do the right thing — eliminating systemic barriers that would make it hard to clean your hands. Hospitals can put gel dispensers everywhere and can make sure carts are available so staff members can keep their hands free to be able to clean up.

I was really intrigued by this article and the accompanying YouTube video:

MetroWest Medical Center – MetroWest Medical Center Boasts Innovation

The one-of-a-kind device, which looks something like a toll-gate, was developed by Lean Process Manager Kevin Frieswick, and works by wiring the dispensers to an arm which blocks access to a room, and only goes up once someone has activated the dispenser.

Staff need only stick their hand under the dispenser to receive a shot of sanitizer, raising the barrier. A motion sensor then waits until the door is clear to lower the barrier.

“I made it out of Radio Shack and Home Depot parts,” said Frieswick, who wired the one-of-a-kind device together. “You're not getting in this room without making a conscious effort to ignore this.” Hospital officials are contemplating whether to pursue a patent for the device, which is being piloted in one unit and may someday be outside every patient room.

What are your thoughts on this? What do you think the pro's and con's are of a method like this — both in theory and in practice?

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Mark Graban
Mark Graban is an internationally-recognized consultant, author, and professional speaker, and podcaster with experience in healthcare, manufacturing, and startups. Mark's new book is The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation. He is also the author of Measures of Success: React Less, Lead Better, Improve More, the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, and the anthology Practicing Lean. Mark is also a Senior Advisor to the technology company KaiNexus.


  1. As a prototype I think it is a good idea. I do have some questions about the room enter-exit sensor.

    My big concern of hand washing in hospitals is visiting families. If the first person washes their hands can the rest of the visitors pile in the room. I know limiting the number of visitors in a room at once is common practice however I see this rule broken very often for the very sick.

  2. This seems like something straight out of ‘Shockwave Rider’.

    Although the intention is good, the implementation treats us like we are not too smart.

  3. Rearden – how does this error proofing treat people as stupid? They aren’t like Frederick Taylor, calling workers stupid and ox-like.

    People in hospitals are very smart… yet hand hygiene practices aren’t followed 100%. It’s not a matter of smart or dumb… it’s about making it hard for smart people to make mistakes. People forget… we’re not perfect (plus management isn’t paying close attention to the hygiene issue typically). A device like this helps, does it not?

  4. Mark, I was referring to the tollgate-styled dispenser which blocks access until one places a hand under the dispenser.

    This seems like yet another example of the dumbing down or ‘sailor proofing’ of a task which takes away one’s sense of personal accomplishment through accountability. And, yes, 100% compliance is too dependent upon humans to be realistic.

    If we are too overzealous in sailor-proofing we risk becoming a dystopia.

    I would hope that healthcare folks would be diligent in this matter.

  5. Is there any risk that a member of the hospital staff would not get to a patient fast enough because of this device? Would there need to be an override? Would the nurse/doctor arriving to administer cpr to a patient in cardiac arrest have to rub in the gel or foam before attempting to save the patients life? Just a thought.

  6. Even that I don’t buy. Lots of hospital TV dramas have people dying on the table because you didn’t resuss within seconds, but in reality I would rather have docs and nurses with clean hands, no matter what.

    We don’t know if 10 other people didn’t die of drug resistant infections because we washed our hands rather than rush straight to our hypothetical patient who was beeping away on the monitor somewhere.

    I still think the problem needs to be relooked at at even more fundamental level. If the door handle from the washroom was literally immersed in a small basin of sterilizing fluid and couldn’t be opened without immersing hands in it, that provides that literal connection between a ‘desired’ function ie opening the door, and an ‘undesired’ function of washing hands.

    It would also be better to get heroism out of healthcare. You might be a heroic young doctor who’s swotted up all the textbooks and paid the big dollars, but the microorganisms don’t care and are living on your skin just as much as on the homeless guy sitting in the emergency room.


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