Every day there are infections passed from one patient to another at hospitals. Each of these infections is a small incident. If the infection is difficult to control and the patient dies, it is a major accident.

The sad part of these infections is that they are almost 100% preventable by simple techniques. Most could be prevents by doctors and nurses properly washing their hands. For an example program see:

http://www.henrythehand.com/pages/content/infection_control.html

Will Sawyer, M.D, is the creator of this program and I’ve asked him to discuss it – and the issue of changing doctor behavior – more extensively at the Medical Error Reduction Best Practices Track at the TapRooT(R) Summit (April 25-28, 2007, in San Antonio).

Sometimes the lessons learned from a fatality can be a simple change for the better.