Optimal hand hygiene is a critical component in any process focused on achieving and sustaining zero incidents of healthcare-associated infections (HAIs).  Healthcare facilities may improve hand hygiene practice by applying a multimodal framework of system and behavioral strategies to investigate, understand, and mitigate gaps in infrastructure and behavioral components of hand hygiene.

​Pennsylvania Patient Safety Authority analysts queried the Pennsylvania Patient Safety Reporting System database for events associated with hand hygiene for the 10-year period of June 2004 through June 2014; the query returned 789 event reports. Analysts reviewed the reports to identify those associated with compliance. Pennsylvania healthcare facilities reported 35 events related to hand hygiene compliance. A sampling of these reports included the following:

• Handwashing was not performed before or after a postoperative dressing change procedure, and no gloves were worn for a dressing change.
• A surgeon did not do a surgical scrub before gowning for the first case, then used foam soap before scrubbing for the second case and touched drapes on the sterile table without being sterile.
• An x-ray tech ignored isolation precautions by not wearing gloves or sanitizing their hands after touching the patient.
• A nurse did not attempt to clean their hands or wear gloves while accessing a cancer patient's port, leaving the room twice and not performing hand hygiene or using clean gloves either time.
• An anesthesia provider suctioned a patient's airway without gloves, wiped his hands on his jacket, and administered intravenous medication without hand hygiene or gloves. The nurse offered him hand sanitizer prior to medication administration, but the physician refused.
• A nurse inserted a rectal suppository in a patient and then performed a blood draw without washing their hands between procedures.