System Failure versus Personal Accountability — The Case for Clean Hands

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 . . .