Great advances have been made in standardization and human factors engineering that have reduced variability and increased reliability in healthcare. As important as these advances are, the authors believe there is another important but largely ignored layer to the safety story in healthcare that has prevented us from progressing. In the field of infection prevention and control (IPAC), despite great attempts over several decades to improve compliance with hand hygiene, surveillance, environmental cleaning, isolation protocols and other control measures, very significant challenges remain. We believe this failure is in part due to the power gradients, often dysfunctional relationships and lack of safety mindfulness that exist in hospitals and healthcare more generally. Furthermore, safety culture requires different approaches and considerable ongoing attentiveness. If this is the case, and the authors contend in this paper that it is, then the role of the front line is much more important than many of our healthcare safety and IPAC approaches suggest.

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