ABSTRACT
Within the last few years the subject of hospital infection control has become the subject of much media attention (e.g., BBC Panorama, 2008). A number of high profile hospital outbreaks within the UK involving bacterium such as Clostridium difficile (C. diff.) and MRSA (Methicillin-resistant Staphylococcus aureus) and the number of mortalities resulting from these outbreaks, has made infection control into a central priority for the UK NHS and other health care systems worldwide (Allegranzi et al., 2007). Much of the debate so far has concentrated on improving hygiene within hospitals (e.g., hand washing), very little research has been conducted on the wider behavioural, social and organisational factors that may also determine infection control outbreaks (Griffiths, Renz and Rafferty, 2008). The intention of the present study is to consider the potential of adopting a systems
ergonomic perspective towards hospital-based infections. More specifically, the paper describes the advantages to be gained from applying existing systems analysis techniques to infection outbreaks and using these to draw out both lessons learnt as well as strategies for improvement. In order to demonstrate the value of such an approach the paper focuses on a specific case study namely, the Maidstone and Tunbridge Wells NHS Trust outbreaks which occurred between 2005-2007 (Healthcare Commission, 2007).
