The necessity to prevent harm and death from avoidable infections has received significant attention during the last decade and many of the conventional weapons in the patient safety armoury have been used with good effect, for example root cause analysis (RCA) for investigating Meticillin-resistant Staphylococcus aureus (MRSA) bacteraemia.

Human factors approaches per se have been addressed in a piecemeal manner within infection prevention and control, with some interesting examples, mainly centred on checklists. However, this has tended to take place in a vacuum and has not been as transparent as it might have been in order to inspire others to consider such an approach. The engagement of leading human factors and ergonomics experts and the piecing together of the science of human factors alongside conventional infection prevention thinking has not been systematically addressed for healthcare.

This paper argues that the time has come to strengthen infection prevention and control capacity and capability by embedding human factors principles, methods, expertise and tools. To address how we can better develop interventions that work safely within the complex sociotechnical system that is healthcare, a root and branch review of infection prevention measures through a human factors lens is suggested as a way forward. This is essential if the requisite behaviour change is to be achieved in healthcare at this critical juncture, if the gains of recent years are to be maintained and if the defects in processes and adherence to protocols are to be successfully overcome.