This paper covers the history of infection control and the role human factors engineering, and macroergonomics in particular, has played and will continue to play in the reduction of hospital-acquired or nosocomial infections—a key aspect for enhancing patient safety and quality of care. Semmelweis is considered the father of modern hospital infection control and epidemiology programs; and he used human factors engineering and a systems approach to solve infection control problems by considering societal, organizational, environmental, task, tools and person factors in his investigations. Today, the IOM stresses the importance of organizational and process designs and a “culture of safety” for the reduction of medical errors. Examples of current problems and areas for future infection control and human factors research are presented, including design issues, change management and safety culture. All levels of the work system—from the microenvironment level issues such as noise and light to the macro environment level issues such as organizational culture and societal factors—must be taken into account for controlling nosocomial infections and enhancing patient safety. “ Because of my convictions, I must here confess that God only knows the number of patients that have gone prematurely to their graves by my fault. I have handled cadavers extensively, more than most accoucheurs. As painful and depressing, indeed as such an acknowledgement is, still misfortune should not persist forever, for the truth must be made known to all concerned.” Ignaz Phillip Semmelweis, Budapest Hungary 1861
Human factors systems approach to healthcare quality and patient safety