Building a Culture of Safety: Experts Call for a Reboot on Stethoscope Hygiene and Everyday Infection Risks

Speaking with Infection Control Today^® (ICT^®) in this third and final segment, a panel of leading infection prevention and perioperative experts explored one of the most overlooked contributors to health care-associated infections: the small, familiar items that clinicians use every day. Stethoscopes, jewelry, phones, rings, doorknobs, and even providers' own hands came under scrutiny as the speakers connected safety culture, human behavior, and the challenge of making invisible risks visible.

Peter Graves, MSN, RN, CNOR, opened the conversation with a simple but powerful message. “It is about developing that culture of safety. Stethoscope cleaning is part of the safety culture that we have to ingrain, and we do not do enough of it.” He recalled that when he went to nursing school “back in the 1800s it seems like,” the topic was covered, but not emphasized. Today, he said, stethoscope hygiene must align with hand hygiene and environmental hygiene as a unified set of expectations. “All of these things come together as one for a better term because that is what is going to make a big difference in infections, not just today but tomorrow.”

Aaron Woodall, MPH, CIC, LTC-IP, expanded on this idea by linking stethoscope hygiene directly to risk awareness. “People have to understand the risk of what you are doing,” he said. To illustrate his point, he offered a familiar analogy. “If you go to the gas station, how many people do you see smoking while they are pumping gas? You do not, because people know that there is a major risk to it. You just have to tie the same concept to this.”

Elsy Mady, MSN, BSN, RN, CIC, agreed that risk perception varies widely and shapes behavior. “It depends on how you see the risk,” she said. During hand hygiene rounds, she often encounters staff who skip sanitizer because they believe they did not touch anything significant in a patient room. “You touch the bed maybe. You touched the doorknob. So, your hands are contaminated now.” She described finding a music therapist in an isolation room without PPE [personal protective equipment] because the staff member assumed that simply avoiding direct patient contact meant she was safe. “Your hands are already contaminated,” Mady reminded her.

Mady stressed that the problem often lies in the invisibility of pathogens. She referenced a video that used glowing markers to trace contamination from patient to wound to nurse’s station. “Maybe visualizing the risk can help people see the unseen because we cannot see the germs, and sometimes you are not afraid of what you are not seeing.”

The ICT moderator noted that if pathogens were visible, people would act differently. “If we could see pathogens, then we would be terrified,” they said. “We would actually be more cognizant of them.”

Woodall added that people react intensely to certain threats while ignoring others. “Just tell them there are bedbugs in the room and then you see everybody running,” he said. But many of those same people will stand at the bedside of a patient with Clostridioides difficile without full PPE. “Come on, people,” he said, pointing out the inconsistency.

To overcome these gaps, the panelists described creative educational approaches. Mady recalled a training session in Lebanon where she coated her hands in body paint. “I said, who wants to come and shake my hand? Nobody did.” She also cultured staff rings on agar plates and brought back the results. “Some Pseudomonas, some epidermidis, all kinds of germs were there on their rings,” she said. One nurse had a completely clean ring because she placed it in a bleach solution every night. “It was really good to see,” Mady said, but most people have no idea what lives under their jewelry or long nails in patient rooms.

Graves shared a study that visualized contamination on stethoscopes using agar plates. He described how much impact it had. “I guarantee that will change their behavior,” he said.

Mady concluded that overlooked items need more attention. “Maybe we think these are harmless, but everything in the health care setting is important and is a risk for our patient safety,” she said. “Having the safety culture in mind before doing anything is primordial.”

For Woodall, the path forward begins with relationships. “It really comes down to building a culture of trust to begin with,” he said. Clinicians must trust the guidance provided by infection prevention, not only for patient safety but for staff, family, and community safety. “Infection prevention does not stop at the hospital walls. It continues well past that.”

Once trust is established, Woodall said, organizations can build a culture of safety, then muscle memory. “It will become just part of what we do, as opposed to trying to force feed an organization to follow the rules.” His takeaway was straightforward. “Start with a culture of trust, build the culture of safety, build muscle memory, and in breaking it all down, save lives.”

Graves agreed and emphasized the operating room as a key environment for improvement. “One of the biggest things we can do is really focus on doing the right thing when no one is looking,” he said. He described the thorough cleaning that anesthesia teams already perform during room turnover. “We clean the anesthesia machine, we clean the anesthesia cart, we clean the knobs. We should make sure that we are catching the anesthesia stethoscope as well.” Muscle memory must be built the same way hand hygiene is built. “If we do this the same way each and every time, we will develop that muscle memory, and we will not miss it.”

Missed opportunities, Graves warned, place patients at risk. Many surgical patients are immunocompromised, and a stethoscope may come near the incision. “Regardless of the scenario, doing this each time is going to protect patients.”

The panelists included:
• Elsy Mady, MSN, BSN, RN, CIC, independent infection preventionist consultant
• Aaron Woodall, MPH, CIC, LTC IP, chief of infection and control for the US Department of Veterans Affairs
• Peter Graves, MSN, RN, CNOR, independent perioperative consultant, speaker, and peer-reviewed writer