Can Poor Hand Hygiene Lead to Medical Liabilities and Lawsuits?

Updated: Sep 12

By Paul Gallese

Poor hand hygiene compliance has been linked to increased hospital-acquired infections (HAIs), and health care providers have been sued for negligence resulting in HAIs. With hand hygiene compliance a Joint Commission accreditation requirement and standard of care, poor hand hygiene compliance can be named as a causal factor for an HAI in a liability suit against a healthcare organization or individual provider.

Vitalacy found six major lawsuits (Vitalacy, 2018) resulting from patients acquiring HAIs, with one leading to a damage award of $7.5 million. Poor hand hygiene was noted as a factor in at least two of these six lawsuits.

A woman in a hospital to give birth contracted genital herpes after nurses placed her in the same room as a patient showing signs of an active herpes infection. The nurses then failed to wash their hands properly when moving from the infected patient to others (Barnes, 2009). In another situation resulting in a lawsuit, a hidden camera positioned outside an operating room showed that about half of the physicians entering the room did not wash their hands before going inside (Berens, MJ, 2002).

Poor infection control practices, including not following proper hand hygiene practices, led to six patients being hospitalized with staph infections at a South Carolina clinic. One of the patients died from the infection, and his family sued the clinic (Bean, 2017).

The 2019 CDC report states that more than 119,000 people suffered from staph infections in the U.S. during 2017 – and nearly 20,000 died. The report says progress against these infections is slowing across the country, but some organizations have protected people by making infection control a priority. For example, the U.S. Department of Veterans Affairs medical centers reduced staph infections by 43 percent between 2005 and 2017 by implementing a multi-faceted prevention program including screening, use of contact precautions, and an increased emphasis on hand hygiene.

The cost of preventing and defending against claims related to HAIs and HACs, including the practice of defensive medicine, has been estimated to be $55.6 billion in 2008, or 2.4 percent of total healthcare spending (Mello et al., 2010).

Don’t let your hand hygiene compliance rate fool you

While hand hygiene compliance under 50 percent is insufficient, there is recent evidence showing that the average compliance rate is even lower (McLaws et al., 2018; Eiamsitrakoon et al., 2013; Pan S-C, et al., 2013). That’s because compliance drops off when care providers are not observed, due to the Hawthorne effect.

Simply put, the Hawthorne effect – the alteration of behavior by the subjects of the study due to their awareness of being observed – greatly increases estimated hand hygiene compliance rates. Studies show the overestimation to be as high as 300 percent since compliance drops off significantly when healthcare workers are not directly observed, and most hand hygiene events are not directly observed (Hagel et al., 2015; Srigley et al., 2014).

If the stubborn persistence of HAIs is any indication, the direct observation of hand hygiene compliance – the approach used by most hospitals – is not enough to drive down infection rates and is not enough to protect hospitals from all the medical and legal costs associated with infections. Automated monitoring systems offer the opportunity to increase the number of observations through 24/7 monitoring and through immediate feedback regarding compliance to both caregivers and healthcare organizations.

Automated monitoring systems have improved compliance and reduced infection rates

Automated monitoring systems have improved compliance and reduced infection rates. Michael et al. (2017) reports that an automated system with immediate feedback caused a rapid and sustained improvement in compliance while significantly increasing the number of observations. For example, one unit improved from 54 percent compliance over 12 months based on 88 direct observations to 98 percent compliance over 12 weeks based on 140,000 automated observations.

Another study of an automated system shows an increase of hand hygiene compliance of 25.5 percent, a decrease of healthcare-associated MRSA infections of 42 percent from baseline, and a savings of $434,000 over the study timeframe (Kelly et al., 2016). These results demonstrate how continual feedback from the data led to staff engagement and sustained improvement. “Across the entire hospital, periods of improved hand hygiene compliance led to lower infection rates,” the authors state. “We believe the monitoring system aided nursing leadership’s ability to drive change and improve staff performance, by providing real-time reliable (compliance) data. Continuing feedback allowed for ongoing conversation with frontline nursing staff, and unit-level data allowed for unit-level solutions because staff engagement with the data led to strategic decisions, which resulted in consistent, sustained improvement in hand hygiene performance.”

The infection control approach outlined by Kelly et al, 2016, goes beyond increasing hand hygiene compliance to demonstrating a decrease of HAIs, as well. This is the best defense against medical liabilities and lawsuits, as well as against related risks and costs, such as reimbursement penalties, higher morbidity rates leading to increased readmissions and length of stays, and higher mortality rates.

The Vitalacy Patient Safety Platform was developed primarily to reduce HAIs and HACs, not to monitor hand hygiene compliance for its own sake. This automated approach is designed to gain broad, hospital-wide support for continuous 24/7 workflow monitoring and compliance; this kind of comprehensive approach gathers accurate workflow and compliance data, empowers staff with reminders to take action, and enables the performance improvement required to reduce infections.


Vitalacy, Inc. (2018). Healthcare lawsuits and infection control: an expensive collision. March 30, 2017. Updated Oct. 31, 2018.

Barnes BA. Negligence, medical malpractice, vicarious liability, or patient responsibility: who should pay when a patient contracts MRSA from a healthcare facility? Indiana Health Law Review, 2009;7:335-365.

Berens, MJ. Epidemic infection carves deadly path. Chicago Tribune, July 21, 2002.

Bean, M. Poor hand hygiene linked to 6 staph infections, 1 death at SC pain clinic. Becker’s Hospital Review, July 24, 2017.

Centers for Disease Control and Prevention. Deadly staph infections still threaten the U.S. March 5, 2019.

Mello MM, et al: National costs of a medical liability system. Health Affairs, 2010;29(9):1569–1577.

McLaws M-L, et al: Hand hygiene compliance rates: Fact or fiction?, American Journal of Infection Control (2018). DOI: 10.1016/j.ajic.2018.03.030

Eiamsitrakoon T, et al: Hand hygiene behavior: translating behavioral research into infection control practice. Infection Control and Hospital Epidemiology, November 2013;34(11): 1137-1145. 

Pan S-C, et al: Compliance of healthcare workers with hand hygiene practices: independent advantages of overt and covert observers, Public Library of Science, Jan. 14, 2013.

Srigley JA, et al: Quantification of the Hawthorne effect in hand hygiene compliance monitoring using an electronic monitoring system,: a retrospective cohort study, BMJ Quality & Safety, Dec. 2014;23(12):974-980. 

Hagel S, et al: Quantifying the Hawthorne effect in hand hygiene compliance through comparing direct observations with automated hand hygiene monitoring, Infection Control and Hospital Epidemiology, August 2015;38(8):957-62.

Kelly JW, et al: Electronic hand hygiene monitoring as a tool for reducing healthcare-associated methicillin-resistant Staphylococcus aureus infection. American Journal of Infection Control, 2016;44:956–957.

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