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A reduction in BSI (outcome) was achieved between 2000 and 2011, 57 and the follow-up period of a decade was extensive to allow for improved hand hygiene behavior to become embedded. However, when direct observation is used, there will always remain the possibility of overestimation of hand hygiene compliance due to the Hawthorne effect (measurement error). The WHO guidelines 11 provide a hand hygiene compliance audit tool for ABHR or soap and water use and instructions for the technique of hand hygiene. 11 The audit tool does not include a measurement of the hand hygiene technique. 11 The correct hand hygiene technique requires the actor to perform seven poses while using ABHR: rubbing palms together in a circulation motion, fingertips moving in circular motion on the palm of the opposite hand, palm to palm with fingers from opposing hands interlocking, four fingers grip interlocking four fingers on the opposing hand, palm of hand onto the back of the opposing hand with fingers between fingers, rubbing thumbs, rubbing wrists. Ineffective hand hygiene technique may result in a hand hygiene intervention failing to affect the rate of MDROs.

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