A systems ergonomics analysis of the Maidstone and Tunbridge Wells infection outbreaks.

This paper describes a systems ergonomics analysis of the recent outbreaks of Clostridium difficile, which occurred over the period 2005-07 within the UK Maidstone and Tunbridge Wells NHS Trust. The analysis used documents related to the outbreak, alongside the construction of a system model in order to probe deeper into the nature of contributory factors within the Trust. The findings from the analysis demonstrate the value of looking further at cross-level and whole-system aspects of infection outbreaks. In particular, there is a need for further study of the causal relationships that exist between hospital management and clinical management levels within the system. Finally, the paper discusses ways forward and strategies that could be adopted in order to limit the outbreak of hospital-related infections and shape future research. The approach used for the system analysis described in the paper could be used by healthcare practitioners and ergonomists to probe deeper into the causes of infection outbreaks and to extend the scope of interventions aimed at preventing their occurrence.