The Joint Commission on Accreditation of Healthcare Organizations UCAHO) mandates a hospital-wide infection control program.' National, state, and local healthcare guidelines and resources address infection control issues including asepsis, handwashing, isolation precautions, Universal Precautions (UP), and waste disposal. One important aspect of an infection control program is the monitoring of compliance with policies and procedures. We report a system of monitoring compliance with infection control policies and procedures through the use of confidential infection control violation reports.

Bishop Clarkson Memorial Hospital is a 550-bed tertiary care center that has an epidemiology services department consisting of a medical director, associate medical director, and two nurse epidemiologists. Hospital personnel have been encouraged through formal and informal educational sessions to report infection control violations to the service. Prior to 1986, infection control violations usually were noted through special studies such as isolation precautions monitors and surveillance activities. Occasionally, employees told Epidemiology Services about a witnessed violation but were very hesitant to document the incident because of fear of retaliation, harassment, and job loss. Peer pressure appeared to play a role in this hesitation.