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 adopted in order to limit the outbreak of hospital-related infections and shape future research.