Major Article|Articles in Press

Using a human factors framework to assess clinician perceptions of and barriers to high reliability in hand hygiene

Published:March 15, 2023DOI:


      • Clinician perspectives on sustaining hand hygiene reliability are poorly defined.
      • Human factors engineering is effective but underutilized in infection prevention.
      • Using this framework, we surveyed pediatric clinicians about hand hygiene.
      • Organization, environment, tasks, and tools identified as barriers to hand hygiene.


      Hand hygiene (HH) is critical to prevent health care-associated infections (HAIs). Clinician perspectives on maintaining high reliability are poorly defined.


      We surveyed physicians, nurse practitioners, and physician assistants to understand perceptions of and barriers to high reliability in HH. The Systems Engineering Initiative for Patient Safety 2.0 model was used to develop an electronic survey exploring 6 human factors engineering (HFE) domains.


      Among 61 respondents, 70% perceived HH as “essential” to patient safety. While 87% reported alcohol-based hand rub (ABHR) availability as very effective in improving HH reliability, 77% reported dispensers to be “sometimes” or “often” empty. Clinicians in surgery/anesthesia were more likely than those in medical specialties to note skin irritation from ABHR (OR 4.94; 95% CI 1.37-17.81) and less likely to believe feedback was effective in improving HH (OR 0.26; 95% CI 0.08-0.88). One quarter of respondents indicated the layout of patient care areas was not conducive to performing HH. Staffing shortages and the pace and demands of work precluded HH for 15% and 11% of respondents, respectively.


      Aspects of organizational culture, environment, tasks, and tools were identified as barriers to high reliability in HH. HFE principles can be applied to more effectively promote HH.

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