Infection complicates accidental injury and surgery with predictable regularity.

Nosocomial (hospital) infection complicates the stay of 5-15% of inpatients and kills around 2000 Canadians each year.

However, medical malpractice plaintiff counsel know the frustration of rarely being able to prove negligence as a cause.

It is usually impossible to show Causation, particularly long after the event.

Furthermore, community standards for prevention of cross-infection are so poor as to torpedo most such Causes of medical malpractice Action.

As the United States Centers of Disease Control and Prevention (CDC) has said, "Handwashing is the single most important means of preventing the spread of infection."

However, failure regularly to wash hands between patients represents actual community Standard of Care in North American hospitals.

At best, less than three-quarters of registered nurses comply, and figures from most studies, including those for physicians, are considerably worse.

There is not even any question that adequate hand washing effectively removes the dangerous transient bacteria from the hands.

Well-reasoned estimates suggest that a one-and-a-half to twofold increase in compliance with standard handwashing policy would reduce nosocomial infection rates by 25-50%.

However, changing the habits of hospital caregivers is the problem: heightened scrutiny, educational and motivational efforts have only limited and temporary benefit.

Surgical gloves not only develop microscopic holes during normal use, but their wearers frequently contaminate previously clean surfaces before they remove the gloves, and soil their own hands during removal.

Casual observation will show that some nurses and physicians treat the wearing of surgical gloves as a substitute for handwashing, rather than an adjunct.

A recent study from Brazil has confirmed previous findings that potentially dangerous bacteria can be cultured from most stethoscopes in clinical use.

The commonest germ isolated is Staphylococcus Aureus, including the Methicillin-Resistant (MRSA) variety.

This potentially-lethal infection is an increasing hospital problem, in intensive care units in particular, and now occasionally appears in the community.

Once hospital cross-infection is recognised to have taken place, isolation precautions significantly reduce subsequent transmission to other patients.

The stable-door is now locked - but one of the horses has already bolted.

Simply wiping stethoscopes with 70% alcohol between patients would probably make a material difference to cross-infection - but the precaution has not yet been adequately tested or instituted as a routine.

Blood-pressure cuffs, including those that are not visibly contaminated by blood or other body fluids, readily demonstrate colonisation with potentially harmful bacteria.

Isolation of such germs does not prove that inanimate objects like stethoscopes and blood-pressure cuffs are important vehicles of hospital cross-infection.

There are very few such studies, despite the enormity of the problem, but routine use of a single blood-pressure cuff has been shown to explain patterns of cross-infection in a neonatal special care nursery.

Disposable covers for blood-pressure cuffs have been designed and are commercially available...but are not yet in regular use.

Hospital beds, linen, side-tables, and nurse’s gowns and uniforms have been shown to be readily and regularly contaminated by Staphylococcus Aureus and other potentially dangerous germs, including those that can cause epidemic diarrhea and vomiting.

A third of "clean" sampled surfaces of anesthesia and monitoring equipment in operating rooms were found by forensic testing to be contaminated by blood.

The significance of this somewhat depressing picture to claimant and defence counsel is that hospitals in general, and emergency rooms and intensive care units in particular, are dangerous places for those who have suffered personal injury.

Although the injury damages may be compounded by infection contracted during hospital treatment, proving a novus actus interveniens caused by medical and nursing negligence is rarely possible.

Occasionally, eye-witnesses of a particular physician’s unusually poor hygiene will provide strong circumstantial evidence.

Exceptionally, investigation of nursing, medical or surgical care of a couple of patients who were treated simultaneously will reveal a pattern that explains cross-infection on balance of probability.

Rates of medical errors, and of negligent medical errors in particular, will not be decimated without a revolutionary systemic change in the approach to risk management,

Similarly, potentially preventable cross-infection in our hospitals will remain at its unacceptably high level until known and simple procedures are conscientiously applied by caregivers.

Meantime, counsel will continue to grapple with secondary damage that occasionally exceeds that of the original personal injury.