Jamar Shaw
Atlanta, Georgia, United States

“Do you really think we’re killing our patients because we’re not washing our hands?” A clinical leader responsible for preventing healthcare-associated infections asked this question during rounds. I remember the disbelief in her question because surely modern medicine had moved beyond something so primitive.

Yet the question was as relevant then as when Ignaz Semmelweis¹ asked it in Vienna and Budapest in the 1840s. And it was particularly relevant in 2015, when bacterial outbreaks struck special-care nurseries at the University Hospital of the West Indies in Kingston and Cornwall Regional Hospital in Montego Bay. Early reporting described 42 infected newborns and 18 deaths.² A subsequent statement to Jamaica’s Parliament reported 483 nursery admissions, 45 cases of sepsis, and 19 deaths, a case-fatality rate of 42.2%. Most of the babies who died were extremely premature, weighed less than two pounds, or were critically ill; Klebsiella and Serratia were identified.³

In 2022, another outbreak unfolded in the neonatal unit at Victoria Jubilee Hospital in Kingston. Klebsiella pneumoniae was implicated, and twelve newborns died. The health minister described severe staffing pressure: approximately one nurse for seven or eight infants, compared with an ideal ratio of one to two in that environment.⁴ An honest infection-prevention analysis cannot claim that every transmission event began with an unclean hand.^5-7 But it cannot pretend that hands are incidental either, because organisms can spread in healthcare settings through contaminated hands, equipment, and environmental surfaces, as well as failures in aseptic care.^5-7

The World Health Organization’s Five Moments for Hand Hygiene are designed to interrupt the chain: they remind one to sanitize one’s hands before touching a patient, before a clean or aseptic procedure, after body-fluid exposure risk, after touching a patient, and after touching the patient’s surroundings.⁸ In a neonatal unit, those moments are not ceremonial. Premature infants have immature defenses and frequently require invasive devices, increasing their vulnerability to healthcare-associated infection.⁹ Hand hygiene cannot solve understaffing, crowding, contaminated water, poor equipment processing, or inadequate environmental cleaning. But it does something immediate: It helps prevent our hands from carrying disease to the next patient.

That is why the leader’s question stayed with me. A leader’s skepticism does not remain private. It reaches the nurse deciding whether to stop between urgent tasks, the physician moving quickly from one bedside to another, and the trainee watching which rules leaders honor when no auditor is present. Culture trickles down long before infection spreads across.

There is something else she did not know when she asked me that question. One of the babies lost in Jamaica was my niece. Before her, there had been several miscarriages, each one a future imagined and then buried before our family could hold it. Her arrival carried the fragile hope that grief had finally loosened its grip—that after years of thunder, the sky had opened just enough to let color through. She was not merely a neonatal statistic or one more case in an outbreak report. She was proof, to us, that joy could return after repeated loss. Then the hospital called our family back into reality.

Her death changed the sound of every hand-hygiene debate I would hear afterward. When someone reduces compliance to a dashboard percentage, I remember that every denominator is somebody’s answered prayer. When a leader asks whether unclean hands can really kill patients, I do not hear a theoretical question. I hear my niece’s absence.

Can I prove from the public record that a specific missed hand-hygiene opportunity caused her infection? No. Scientific integrity matters, especially when grief wants certainty. Public investigations do not trace one worker’s hand to one child’s bloodstream. Environmental reservoirs, shared equipment, invasive-device care, overcrowding, inadequate staffing, and delayed recognition may all have contributed.

But uncertainty about one transmission event does not erase what generations of evidence have established: contaminated hands can transmit pathogens in healthcare, and appropriate hand hygiene reduces opportunities for that transmission.^7,10 Prevention asks us to act before causation becomes a memorial.

Semmelweis did not initially know why chlorinated lime worked. He knew mothers stopped dying. Today we can culture organisms, sequence genomes, map transmission networks, and measure compliance in real time. What we still struggle to cleanse is the belief that expertise makes our hands innocent.

So, do I really think we can kill patients because we do not perform hand hygiene properly? Yes. Not because every missed moment ends in infection. Most do not. But some missed moments complete that chain. For the patient at its end, premature, intubated, catheterized, immunocompromised, the difference between clean and contaminated hands may be the difference between recovery and a death certificate. Hand hygiene is not a housekeeping preference, a poster, or an observation quota. It is a culture of admission that although we enter the room to heal, we can also carry harm. The question is how many deaths it will take before every healthcare culture behaves as though it believes this.

References

1. Ataman AD, Vatanoğlu-Lutz EE, Yıldırım G. Medicine in stamps-Ignaz Semmelweis and puerperal fever. J Turk Ger Gynecol Assoc. 2013;14(1):35-39. doi:10.5152/jtgga.2013.08
2. Laville S. Jamaica battles hospital infections that have killed 18 babies in three months. The Guardian. October 20, 2015. Accessed September 5, 2026. https://www.theguardian.com/world/2015/oct/20/jamaica-hospital-infections-killed-babies
3. Ministry of Health and Wellness, Jamaica. Statement to Parliament: outbreak of bacteria at UHWI & CRH special care nurseries. Published October 28, 2015. Accessed September 5, 2026. https://www.moh.gov.jm/presentation/statement-to-parliament-by-minister-of-health-hon-dr-fenton-ferguson-tuesday-october-27-2015-outbreak-of-bacteria-at-uhwi-crh-special-care-nurseries/
4. Smith A. 12 babies die from bacterial infection at Victoria Jubilee Hospital. Jamaica Observer. October 27, 2022. Accessed September 5, 2026. https://www.jamaicaobserver.com/2022/10/27/12-babies-die-from-bacterial-infection-at-victoria-jubilee-hospital/
5. Centers for Disease Control and Prevention (CDC). About Acinetobacter. Updated January 31, 2025. Accessed September 5, 2026. https://www.cdc.gov/acinetobacter/about/index.html
6. CDC. About Klebsiella. Updated June 12, 2025. Accessed September 5, 2026. https://www.cdc.gov/klebsiella/about/index.html
7. World Health Organization (WHO). WHO guidelines on hand hygiene in health care. Published January 15, 2009. Accessed September 5, 2026. https://www.who.int/publications/i/item/9789241597906
8. WHO. Five moments for hand hygiene. Published March 4, 2021. Accessed September 5, 2026. https://www.who.int/publications/m/item/five-moments-for-hand-hygiene
9. Brady MT. Health care-associated infections in the neonatal intensive care unit. Am J Infect Control. 2005;33(5):268-275. doi:10.1016/j.ajic.2004.11.006
10. CDC. About hand hygiene for patients in healthcare settings. Updated February 27, 2024. Accessed September 5, 2026. https://www.cdc.gov/clean-hands/about/hand-hygiene-for-healthcare.html