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Infection prevention through education
7 reasons why infections still occur in hospitals which we know how to prevent
Why prevention is not just a written procedure: seven system barriers, supported by data and evidence-based interventions.
It is not about what we do not know. Each of the seven reasons is backed by evidence, and for each, there are interventions supported by research and by infection prevention and control practice.
In 1847, at the Vienna General Hospital, Ignaz Semmelweis introduced handwashing with a chlorinated solution before examining patients in the obstetric clinic. Mortality from puerperal fever dropped dramatically after this measure was introduced.
Today, in hospitals across the European Union and the European Economic Area, approximately 4.3 million patients acquire at least one healthcare-associated infection each year. The ECDC estimates that at least 20% of these infections can be prevented through sustained, multimodal infection prevention and control programs.
This raises an uncomfortable question. If we have known for nearly two centuries how important prevention is, why are we failing to apply it consistently?
The answer is not just about what people in hospitals know or their training. The barriers are largely systemic: what is measured, the available resources, program structure, feedback, time, and the pressure of antimicrobial resistance.
Sources:
World Health Organization, "Commemorating the impact of Semmelweis’ work on global health". European Centre for Disease Prevention and Control (ECDC), Point prevalence survey 2022–2023, published in 2024.
“If I had to choose a single principle, it would be consistency. Prevention is not about spectacular gestures, but about following the same correct procedures, by well-trained staff, every day and for every patient.”
Actual practice
What is declared is not always what is done
Self-assessment can overestimate compliance
In a study conducted in six hospitals in Germany, researchers compared the hand hygiene compliance self-reported by doctors and nurses with that observed directly, in relation to the five moments for hand hygiene defined by the WHO.
The results showed that overestimation was higher when observed compliance was lower. For "before an aseptic procedure," the difference between self-assessed and observed compliance reached 61.7% for doctors and 37.2% for nurses. For "after touching patient surroundings," the difference was 15.5% and 9.6%, respectively.
This does not mean that the staff is "lying." It means that the perception of one's own practice is not the same thing as the measurement of that practice.
If you want to know where a team actually stands, you need measurement. In the case of hand hygiene, direct observation based on the five moments recommended by the WHO can provide a starting point for identifying areas where compliance needs to be improved.
61.7%OVERESTIMATION OF COMPLIANCEamong physicians
37.2%OVERESTIMATION OF COMPLIANCEat the assistants
15.5% · 9.6%OVERESTIMATION OF COMPLIANCE AFTER CONTACT WITH THE PATIENT ENVIRONMENTphysicians · nurses
What works
- Direct observation, reported according to the five WHO moments, not just questionnaires;
- Baseline measurement, to establish a reference point;
- Feedback provided to the team, based on observed data;
- Repeat measurement, to see if the change is sustained.
You cannot constantly improve what you do not measure.
Source: Lamping J et al. Antimicrobial Resistance & Infection Control. 2022;11:147. doi:10.1186/s13756-022-01188-7.
The invisible result
You never see what you have prevented.
Prevention has a problem that treatment does not: the good result is invisible
When you treat an infection, the result can be observed. When you prevent an infection, there is no clear moment where you can say: this is the infection I just prevented.
This leads to one of the fundamental difficulties of prevention: correct behaviors must be maintained even when there is no visible result to confirm them immediately.
Audit and feedback can make visible what is otherwise hard to track: whether recommended practices are being followed and whether compliance is changing over time.
A Cochrane review updated in 2026, which included 292 studies, showed that audit and feedback were associated with a median absolute increase of 2.7% in the desired practice. However, the effect varied considerably between studies, and how feedback is provided matters.
That is why the simple fact that an "audit is being performed" is not enough. It matters what is measured, how relevant the feedback is, how recent it is, and whether it is followed by action.
2.7%ABSOLUTE MEDIAN INCREASEOF DESIRED PRACTICEWITH AUDIT AND FEEDBACK
INVISIBLEPREVENTION RESULTCANNOT BE OBSERVED DIRECTLYWHEN THE INFECTION DOES NOT OCCUR
What works
- periodic audits
- specific, recent, and relevant feedback for the team
- comparing results over time
- establishing improvement measures based on data
Prevention must be measured precisely because its result is not visible.
Source: Ivers N et al. Audit and feedback: effects on professional practice. Cochrane Database of Systematic Reviews. 2026;6:CD000259. doi:10.1002/14651858.CD000259.pub5
The missing resource
When there are not enough people, the protocol does not reach the patient.
A correct procedure cannot indefinitely compensate for a lack of human resources.
A protocol can state exactly what needs to be done. But applying it requires people, time, and working conditions that allow for its observance.
The study by Shang et al., conducted at the unit level and based on data from over 100,000 patients, found an association between understaffing of nursing personnel and the occurrence of healthcare-associated infections. Patients admitted to units where both day and night shifts were understaffed had a higher probability of subsequently developing a healthcare-associated infection.
The problem is not just the number of people providing direct care.
Infection prevention and control programs also need dedicated staff. In a study of 390 hospitals, the APIC (Association for Professionals in Infection Control and Epidemiology) calculator classified 79.2% of the analyzed hospitals as having IPC (Infection Prevention and Control) staffing levels below the expected level, based on the characteristics and complexity of the programs.
That changes the perspective. It is not enough for the procedure to exist. There must also be the actual capacity to apply, monitor, and improve it.
15%PATIENT-DAYSwith insufficient nursing staffON THE DAY SHIFT
6.2%PATIENT-DAYSwith insufficient nursing staffIN BOTH SHIFTS
79.2%OUT OF 390 HOSPITALSwith HAI prevention staffBELOW EXPECTED LEVEL
What works
- staffing PCI according to the complexity of the activity;
- allocating real time for prevention activities;
- procedures adapted to real working conditions;
- products and materials available at the point of care;
- monitoring workload and compliance with practices.
A good protocol cannot replace a human resource that does not exist.
Sources: Shang J et al., Journal of Nursing Administration. 2019;49(5):260-265. doi:10.1097/NNA.0000000000000748; Bartles R, Reese S, Gumbar A., American Journal of Infection Control. 2024;52(12):1345-1350. doi:10.1016/j.ajic.2024.09.004.
What changes when there are too few people
Over 100,000patients included in the analysis by Shang et al.
390hospitals analyzed in the study on infection prevention and control staff
79.2%of the hospitals analyzed had a level of IPC staff below the expected level
Beyond the procedure
There are procedures, but there isn't always a schedule.
A procedure states what must be done. A program creates the conditions for that thing to happen consistently.
A written procedure is important. But, on its own, it does not represent an infection prevention and control program.
A functional program entails clear responsibilities, supervision, training, monitoring, auditing and feedback, epidemiological data, and the ability to intervene when results indicate a problem.
WHO data show how vast the gap is between the existence of recommendations and their implementation: in the 2019 global assessment, only 15.2% of the healthcare facilities evaluated met all minimum requirements for infection prevention and control programs.
At the same time, the WHO shows that the effective implementation of infection prevention and control programs can prevent approximately 70% of healthcare-associated infections. This estimate refers to the effective implementation of IPC programs and the practices that comprise them, not to a universal proportion applicable to every hospital.
The difference between the two situations is essential: knowing what needs to be done is not the same as having a system that makes consistent application possible.
70%OF HEALTHCARE-ASSOCIATED INFECTIONSthat can be prevented through IPC programsEFFICIENTLY IMPLEMENTED
15.2%OF THE HEALTHCARE FACILITIES EVALUATEDmetALL MINIMUM REQUIREMENTS FOR IPC
What works
- a person or structure with clear responsibility for IPC;
- dedicated time and resources;
- active infection surveillance;
- monitoring of practices;
- audit and feedback;
- coordinated implementation of program components.
A procedure is a document. A program is a system that puts the document into practice.
Sources: World Health Organization. Global report on infection prevention and control. 2022; Tomczyk S et al. The first WHO global survey on infection prevention and control in health-care facilities. The Lancet Infectious Diseases. 2022;22(6):845-856. doi:10.1016/S1473-3099(21)00809-4.
The change that does not last
Training is done once and it self-terminates.
A training session can convey information. It cannot, by itself, guarantee behavioral change over time.
Training is one of the essential components of infection prevention.
But initial training is not the same as maintaining correct practice.
In day-to-day operations, new employees appear, staff changes, different teams, new products, new equipment, and situations that do not perfectly resemble those discussed in a training session.
That is why educational interventions have better results when they are integrated into a broader monitoring and feedback system, rather than being treated as a one-time event.
The useful question is not just "Have they been trained?", but also "What has changed after the training and how do we know the change has been maintained?"
What works
- initial training and refresher sessions;
- demonstrations and materials available in the workplace;
- measuring practice after training;
- performance-based feedback;
- integrating training into the overall IPC program.
Training conveys knowledge. Monitoring and feedback help turn them into repeated practice.
Time pressure
Time pressure can compromise cleaning and disinfection.
The problem is not speed in itself. The problem arises when speed becomes the only criterion.
In a hospital, time is an operational resource.
Patients change, rooms must be prepared, surfaces must be cleaned and disinfected, and activity must continue.
In this context, a natural tension arises between speed and compliance with the necessary steps.
When the pressure to finish quickly becomes the priority, there is a risk that some stages of the cleaning and disinfection process may be treated as secondary.
That is why the speed of releasing a room is not, by itself, a sufficient indicator of a well-executed process.
One must also track whether the cleaning and disinfection stages were properly followed.
What works
- realistic time allocated for cleaning and disinfection operations;
- quality criteria monitored alongside execution speed;
- clear and easy-to-follow processes;
- products and materials available where they are used;
- monitoring of practice, not just working time.
Fast doesn't automatically mean correct. And correctness shouldn't be measured only in minutes.
Safety net
When resistance increases, prevention becomes even more important.
As treatment options diminish, preventing infections becomes increasingly important.
Antimicrobial resistance is changing the consequences of an infection.
When microorganisms become resistant to antibiotics, treatment can become more difficult, and preventing their transmission becomes even more important.
ECDC data for Romania show a particularly concerning trend regarding bloodstream infections caused by carbapenem-resistant Klebsiella pneumoniae: the estimated incidence increased from 7.12 per 100,000 inhabitants in 2019 to 20.31 per 100,000 in 2024 - an increase of approximately 185%. For 2030, the target is 6.76 per 100,000.
This trend does not mean that every infection is inevitable or that disinfection alone can solve the problem of antimicrobial resistance.
It means that infection prevention, surveillance, the judicious use of antimicrobials, and transmission control measures must be viewed together.
20.31CASES PER 100,000 INHABITANTSROMANIA · 2024
+185%COMPARED TO 20197.12 → 20.31 CASES PER 100,000 INHABITANTS
35,000+ANNUAL DEATHSIN THE EU/EEA, ATTRIBUTED TO ANTIMICROBIAL-RESISTANT INFECTIONS
What works
- integrating IPC into strategies to combat antimicrobial resistance;
- surveillance of resistant microorganisms;
- identifying and managing high-risk transmission situations;
- consistent adherence to prevention practices;
- responsible use of antimicrobials.
When treatment becomes more difficult, prevention is no longer just an important component. It becomes even more important.
Sources: European Centre for Disease Prevention and Control (ECDC). Progress towards 2030 targets to combat antimicrobial resistance - 2025 update - Romania; ECDC. Antimicrobial resistance in the EU/EEA (EARS-Net) - Annual Epidemiological Report for 2024.
The safety net is thinning.
Romania · 2019 7.12 cases / 100,000 inhabitants
Romania · 2024 20.31 cases / 100,000 inhabitants
+185%
2030 target
6.76 cases / 100,000 inhabitants
What do all seven have in common?
The seven reasons seem different.
One concerns measurement. Another feedback. Another personnel. Another organization. Another training. Another time. The last one antimicrobial resistance.
But they all lead in the same direction: prevention does not depend solely on knowing what needs to be done.
It depends on the existence of a system in which best practices can be:
- understood
- applied
- measured
- corrected
- repeated
- maintained over time
A procedure can state what needs to be done.
Training can explain why.
A product can be part of the process.
But none of these work in isolation.
Prevention becomes effective when there is an environment in which people have the resources, time, information, and feedback necessary to consistently apply what they know.
If we have known for nearly two centuries what needs to be done, the question is no longer just whether we know. It is whether the system allows us to do the same thing correctly, consistently, every day.
Frequently Asked Questions
Clarifications for medical practice
Why is self-assessment not sufficient for measuring hand hygiene compliance?
Self-assessment of hand hygiene compliance is not sufficient for measuring actual practice, because staff perception of their own practice may differ from what direct observation shows. Objective measurement of practice allows for the identification of differences between perceived and observed behavior.
Can audit and feedback improve compliance with infection prevention and control practices?
Audit and feedback can improve compliance with infection prevention and control practices, although the effect varies depending on the context and how the intervention is designed. Specific, recent, and relevant feedback can help teams identify practices that need improvement and track change over time.
How does staff shortage influence the risk of healthcare-associated infections?
Staff shortages can increase the risk of healthcare-associated infections, as understaffing has been linked in studies to a higher probability of these infections occurring. Furthermore, infection prevention and control programs require dedicated staff sized according to the complexity of the activity.
What is the difference between a procedure and an infection prevention and control program?
The difference between a procedure and an infection prevention and control program is that a procedure describes what must be done in a specific situation, while a program also includes clear responsibilities, training, supervision, monitoring, auditing, feedback, and the ability to intervene based on data.
Why is a single training session on infection prevention not enough?
A single training session is not sufficient for infection prevention over time, as the transmission of information does not guarantee the maintenance of correct behaviors. Practices must be supported by refreshing knowledge, monitoring, feedback, and integrating training into a continuous infection prevention and control program.
How can time pressure affect cleaning and disinfection in hospitals?
Time pressure can affect cleaning and disinfection in hospitals when speed of execution takes precedence over following the necessary steps, and the quality of the process is no longer monitored with the same attention. Therefore, working time must be analyzed in conjunction with the quality criteria of the cleaning and disinfection process.
Why does infection prevention become even more important when antimicrobial resistance increases?
Infection prevention becomes even more important as antimicrobial resistance increases, since some infections may become more difficult to treat as antimicrobial options diminish. Preventing transmission, surveillance, and infection control must therefore be integrated into strategies for combating antimicrobial resistance.
What is the central idea behind the seven reasons why infections that we know how to prevent still occur in hospitals?
The core idea behind the seven reasons why hospital-acquired infections that we know how to prevent still occur is that prevention depends not only on the existence of knowledge and procedures, but also on how the system enables the application, measurement, monitoring, and maintenance of correct practices.
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The quote in this material comes from an exclusively educational conversation focused on best practices in clinical disinfection. Prof. Univ. Dr. Codruța Nemet expresses strictly professional opinions and does not recommend or endorse any commercial products.
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