When you are very sick, you go to the hospital to get better. But what if the hospital you choose actually makes you sicker, or even kills you?
"The worst thing is to go to a hospital to not die from one thing, and then to end up dying from something else," said Dubner.
Actress Alicia Cole never thought she would almost die from a hospital-acquired infection three years ago.
"I was just living my dreams," Cole, 47, said. "I had two national Budweiser commercials running. I was representing the state of California against childhood obesity. Everything was good."
But Cole's life changed when a routine gynecological procedure at a Los Angeles area hospital went terribly wrong.
"The next day after surgery, I was very nauseous and I had a fever," Cole said. Soon, it became clear that Cole had contracted a necrotizing fasciitis, or "flesh-eating disease" -- one of over 1.7 million hospital-acquired infections that are contracted annually in the United States.
"My stomach just rotted, right before my eyes. It looked like black tar, or burned rubber. I was swelling. It was horrible," Cole said. Even worse, she said, "What happened to me in the hospital was absolutely preventable."
Coles attributes her infection to the carelessness of health care personnel, who she says failed to observe basic sanitary standards during her surgery and post-operative care.
Cases like Cole's could be prevented through what seem like common-sense strategies, such as hand washing -- but old habits die hard, explain Levitt and Dubner.
"Studies have shown that hospital personnel wash or disinfect their hands fewer than half the times they should," Levitt and Dubner write. "And doctors are the worst offenders, more lax than either nurses or aides." In fact, one Australian study reported a hand washing compliance rate of only 9 percent.
Low Hand Washing Rate Among Doctors
Why would doctors, who are supposed to cure diseases, not cause them, be so careless about hand washing?
The connection between dirty hands and deadly infections has been known for over 150 years, since Austrian doctor Ignatz Semmelweis insisted that colleagues wash their hands before delivering babies, drastically cutting deaths among new mothers.
But the reasons for low rates of hand washing compliance among doctors are complex. Dr. Craig Feied, an expert in emergency medicine who has treated over 80,000 patients, estimates that sometimes he would interact with more than 100 patients per shift.
"If you look at a busy nurse, who might touch 100 or 200 patients during a shift, going back and forth from room to room and area to area, the number of times they would have to wash their hands can add up to half the shift time or more," said Feied.
"We're so distracted, whether you're a physician in the hospital or a nurse. You have so many competing interests, to get your work done, that it's very easy to forget that you didn't stop after the patient and wash your hands," said physician Paul Silka, of Cedars-Sinai Medical Center in Los Angeles.
'Hand Hygiene Sheriffs' Reward Hand Washing
To encourage hospital workers to maximize "hand-hygiene compliance," Silka and his colleagues decided to take action. They distributed bottles of alcohol-based hand sanitizer every morning. They even took a page from the Wild West, creating what they called a "posse" of hand hygiene sheriffs.
"We'd try to capture the physicians on rounds, and in a friendly way, encourage them to wash their hands," said Silka. If we saw somebody washing their hands, we would reward them." Doctors who followed the hand washing guidelines received rewards, like Starbucks gift cards.
But it wasn't enough, said Silka. "Ultimately, we had to give physicians a visual example, from a microbiological standpoint, of what their hands would look like if they didn't wash."
So, they set up a simple science project.
Germ-Laden Petri Dishes Made Into Screen Saver
The hospital's epidemiologist, Rekha Murthy, asked colleagues to press their hands into petri dishes and sent them to a lab for processing. The level of contamination shocked the staff. The petri dishes "looked nasty," said Silka.
But the experiment worked. Cedars-Sinai administrators turned the germ-laden petri dishes into the hospital's computer screen saver, forcing staff constantly to look at the images.
"Doctors saw this image of this disgusting pathogen-filled hand and that was the trick that, for whatever reason, made them respond," said Dubner. "It was so successful that not only did it make Cedars-Sinai hand hygiene improve to almost 100 percent, but hospitals around the country started to copy the solution."
Dubner adds that best solutions are often the most cost effective and straightforward. "Washing hands is one of the simplest fixes" to improve hospital-acquired infection rates, Dubner said.
But even freshly washed hands are no match for common, dirty objects, like keyboards and door knobs. "That's why sometimes design and technology offer the solution, and there are things you can do in hospitals to stop bacteria from spreading that go beyond washing hands," he said.
Cedars-Sinai Medical Center takes extra steps to avoid contamination by training its cleaning staff to focus attention on objects like bed rails, bedside telephones, tables and chairs. Curtains separating patient beds are made from special anti-bacterial fabrics, and some patient rooms feature "negative pressure" ventilation systems that keep contaminated air from being recirculated throughout the hospital and causing new infections.
Even Doctors' Neckties Carry Germs
In the war against hospital infections, even something as innocent as the necktie is a target. A study from New York Hospital showed that almost half of doctors' neckties carried germs, and one out of four carried potentially harmful staph bacteria. In fact, the United Kingdom's Department of Health has banned doctors from wearing neckties, watches and jewelry.
Banning neckties and scaring doctors with graphic screen savers may seem over the top, but for patients like Cole, living with the consequences of hospital-acquired infections, there's no such thing as too much vigilance. While still struggling with the physical aftermath of her near-fatal infection, she has devoted her life to helping other patients avoid hospital infections. (Click here for more information).
"Infections happen because somewhere, someone didn't follow the appropriate procedures, and it spreads just that easily," she said. "When you're a nurse or a doctor and you go in to see a patient, and you decide not to wash your hands, you're making a life or death decision," she said.
CLICK HERE to read an excerpt from "SuperFreakonomics."