In the UK about 5000 people die each year from hospital acquired infections. That equates to 65 000 people since this journal was launched in 1992. This is an intolerable toll, which at least in part is linked to failure of healthcare professionals to clean their hands. Evidence that hand hygiene is effective in reducing infection is compelling and is available in the medical literature.¹ So, why cannot hospitals institute and insist on the sorts of changes that make hand washing become part of actual practice?

Arguably, all improvements in clinical care require an organisational change. Failure to understand clinical practice in organisational terms can slow the introduction of new treatments as well as stall efforts to improve the quality and safety of care. For example, there was about a 10 year delay between publication of convincing research showing that thrombolysis, given appropriately, improves survival following a myocardial infarction and for this evidence based treatment to become part of routine practice.² The knowledge of what worked was out there—but practice did not change. What was needed was a significant change in the organisation of emergency medical care. It seems that healthcare professionals and others are either unable to see the problems—and solutions—in organisational terms or, if they do, lack the skills to make the changes that will lead to improvement. And so, for years patients who suffered heart attacks were not offered life prolonging thrombolysis and today’s patients continue to be exposed to unnecessary risk of contracting hospital acquired infections.

Other sectors, such as the airline and oil industries, have had considerable success in the pursuit of improved safety and better quality of service, and this experience may provide some lessons that can be transferred across to …