Poor Hand Hygiene Contributed to 10 Children’s Deaths

By Clean Hands - Safe Hands

The situation in New Jersey is tragic. An adenovirus outbreak at a rehab facility has killed ten children and sickened 30 others[1] to date.

Unfortunately, suffering and death from healthcare-associated infections (HAIs) is not uncommon. In fact, the World Health Organization estimates that 10% of hospital patients in developed countries will develop an HAI[2]. In the past, the public has largely remained blissfully ignorant about HAIs, but that’s changing as more consumer media outlets are reporting on outbreaks, HAIs, and superbugs, such as the one in New Jersey.

While it’s impossible to definitively know how every case of adenovirus was spread in this particular outbreak, the New Jersey Department of Health conducted a surprise inspection and found several hand hygiene deficiencies.

Becker’s Hospital Review covered the issue, reporting that four out of six staff members were observed not meeting hand hygiene standards:

“In one instance, a nursing assistant removed a patient’s soiled diaper before attaching a respiratory tube to the child using the same gloves. In a separate situation, a licensed practice nurse used gloves to handle a nutrition tube that fed directly into a patient’s stomach. She then removed the gloves and touched a ventilator tube connected to the patient’s tracheal opening without washing her hands. The report also said a respiratory therapist at the facility failed to wash her hands in between handling three different patients.”

It’s quite likely that poor hand hygiene contributed to the deaths of these ten children as well as the 30 others that were sickened…which means that at least some of this was preventable. Hand hygiene is widely accepted as the most important strategy to reduce healthcare-associated infections, yet it remains dramatically inadequate in the vast majority of healthcare facilities[3]. The national average hand hygiene rate is widely reported below 50%[4]; despite this, little is done in most of health systems to provide any real improvement.

As the public becomes more aware of HAIs, demand for better patient care is on the horizon. Patients and their families are becoming more informed about the risks posed by HAIs and poor hand hygiene. As we saw in New Jersey, healthcare organizations run a reputational risk by failing to improve hand hygiene and reduce HAIs. But it doesn’t have to be that way. Electronic hand hygiene reminder systems have shown over and over again that they reduce HAIs, saving lives and preventing suffering.

If you’d like to explore how our system typically doubles hand hygiene performance rates…and has reduced HAIs by between 45% and 81% in 100% of customers following our process for 6 months…download our whitepaper to discover the process. Or here’s a brief video about how the system works.


[1] Michael Nedelman, C. (2018). 30 sickened in adenovirus outbreak in NJ, including 10 children who have died. [online] CNN. Available at: https://www.cnn.com/2018/11/06/health/adenovirus-outbreak-new-jersey/index.html [Accessed 7 Nov. 2018].

[2] Who.int. (2018). Health care-associated infections FACT SHEET. [online] Available at: http://www.who.int/gpsc/country_work/gpsc_ccisc_fact_sheet_en.pdf [Accessed 5 Nov. 2018].

[3] Allegranzi B, Pittet D. Role of hand hygiene in healthcare-associated infection prevention. J Hosp Infect 2009;73:305-15.

[4] Erasmus V, Daha TJ, Brug H, Richardus JH, Behrendt MD, Vos MC, et al. Systematic review of studies on compliance with hand hygiene guidelines in hospital care. Infect Control Hosp Epidemiol 2010;31:283-94.


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