When 'We've Always Done It This Way' Increased Post‑Op Infections
A real-world example of Semmelweis reflex in action
Context
A 350‑bed regional hospital had a long‑standing perioperative protocol focused on systemic antibiotics and operating room sterility. A growing body of small randomized trials suggested that adding a simple preoperative nasal decolonization and chlorhexidine wash for certain procedures substantially reduced surgical site infections (SSIs).
Situation
A surgical nurse coordinator compiled twelve months of internal data and a recent meta‑analysis showing a 60% relative reduction in SSIs for joint replacement patients who received nasal decolonization plus chlorhexidine baths. She proposed a six‑month pilot adding the practice for elective orthopedics, including clear measurement and stopping rules. The proposal was presented to the surgical executive committee, whose senior surgeons were skeptical because they believed existing antibiotic protocols were sufficient and worried about extra steps slowing schedules.
The bias in action
Committee members dismissed the evidence quickly, pointing to historical success metrics and personal experience rather than engaging with the data, and labeled the studies as 'not applicable to our setting.' Several senior surgeons argued that changing workflow for a marginal benefit would disrupt OR throughput and be an unnecessary cost. The nurses' pilot was repeatedly delayed and eventually watered down to an optional checklist item rather than a mandated protocol. Requests for a small controlled roll‑out were rejected on the basis that 'we already know what works here.'
Outcome
Without the pilot, the hospital maintained its current practice and did not formally track nasal decolonization. Over the next year the orthopedic service experienced an uptick in SSIs after a change in supplier and scheduling pressures; internal review later linked a portion of the increase to missed preoperative hygiene steps. When leadership eventually authorized the full decolonization protocol after external pressure, adoption was hurried and inconsistent, delaying the expected reduction in infections.
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