Precaution Signs Fail 87% of the Time

By Clean Hands - Safe Hands

When a patient is in isolation, it’s obviously important for everyone entering and exiting that room to know they’re in isolation. The patient is there for a reason – either they have an infection that could spread to healthcare providers as well as other patients, or their immune system is compromised and they’re susceptible to catching other people’s infections.

Most of the time, the way visitors know a patient is in isolation is due to precaution signage on their door. But signs aren’t enough. We know this anecdotally – recently, we spoke with a nurse who was confused when she learned that the patient she had been tending to for three days had C. diff and somehow, she never noticed the sign. She had never put on personal protective equipment (PPE) and she had not been washing her hands with soap and water before exiting the room.

A recent study[1] backs this up. Trained observers watched clinicians caring for patients who require contact or droplet precautions. A shocking 87% of the time, there were failures. These ranged from violations (entering rooms without some or all recommended PPE) to process or procedural mistakes (including failure to remove PPE correctly) to slips (such as touching one’s face with contaminated gloves).

When precaution signage only works 13% of the time, new strategies to change clinicians’ behavior are required. One effective option is to use a human voice to attract the attention of busy clinicians. A voice breaks through the clutter of signs, lights, beeps and buzzers. Our system’s Real-Time Voice Reminder™ reminds providers to clean their hands upon room entry and exit. It gives those serving isolation rooms more time to put on and remove PPE. And for those leaving C. diff rooms, the voice reminds them to use soap and water instead of sanitizer.

If you’d like to explore how our system typically doubles hand hygiene performance rates and reduces HAIs by up to 75-80%, here’s a brief video about how it works. Or here’s a white paper on How the New Joint Commission Hand Hygiene Standards Could Impact Your Hospital.

[1] Krein, S., Mayer, J., Harrod, M., (2018). Identification and Characterization of Failures in Infectious Agent Transmission Precaution Practices in Hospitals: A Qualitative Study. [online] JAMA Internal Medicine. Available at: [Accessed 7 Aug. 2018].


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