When the place built to save your life becomes a threat to it
I. The Patient Who Came for Treatment
In late January 2001, eighteen-month-old Josie King was admitted to The Johns Hopkins Hospital in Baltimore, Maryland, after suffering first- and second-degree scald burns from bathwater. Over the following two weeks, specialized burn care stabilized her condition. Her skin began to heal, and her clinical team prepared for her discharge.
She did not leave the hospital alive.
While recovering on the pediatric intermediate care unit, an indwelling central venous catheter developed an infection. Clinicians removed the line and started antibiotic therapy. Over the subsequent days, her mother, Sorrel King, observed alarming changes: parched lips, hollowed eyes, and persistent thirst, at one point watching her daughter suck water from a bath sponge. Sorrel King repeatedly voiced concern to nurses and physicians, warning that her daughter was severely dehydrated. Clinical staff reassured her, attributing the toddler’s lethargy to expected recovery regression.
Bedside parental warnings failed to trigger clinical escalation. When her mother noticed the toddler becoming increasingly unresponsive and urged that scheduled narcotics be withheld, the verbal instruction did not halt administration. A nurse administered an ordered dose of methadone. Soon after, Josie suffered cardiac arrest.
The hospital’s initial root cause analysis identified dehydration and an unnecessary dose of methadone. A second investigation, released in 2010, revised that conclusion, adding septic shock from a catheter-related infection and finding that the narcotic was not responsible.
Josie King survived severe burn trauma, yet her condition deteriorated under continuous institutional observation. Her death exposed a fundamental reality of patient safety: clinical expertise can save a life only when hospital communication and surveillance reliably recognize when a patient is slipping away.
II. The Architecture of Hospital Harm
The global scale of healthcare-related injury is substantial. According to global syntheses from the World Health Organization, approximately 1 in 10 patients worldwide experiences harm during healthcare delivery across diverse settings, including outpatient clinics, ambulatory centers, long-term care facilities, and acute hospitals. The WHO estimates that unsafe care across this broad spectrum contributes to three million deaths each year, with more than half of resulting harm estimated to be preventable.
Consider a hypothetical overnight surgical ward where a bedside nurse is responsible for six postoperative patients across separate rooms. A seventy-two-year-old recovering from abdominal surgery complains of restlessness and nausea. With sufficient time for assessment, the nurse could review the patient’s recent observations, check the urinary-output trend and contact the resident about the rising heart rate. On a busy ward, competing medication rounds, documentation and another patient’s intravenous-line alarm may delay that assessment. The concern is not that these findings establish a particular diagnosis, but that a developing pattern of deterioration may go unrecognized.
Within acute-care hospitals, patient injuries typically cluster into healthcare-associated infections, medication errors, and procedural or diagnostic complications. Organizational strain, such as nurse understaffing and clinical fatigue, operates not as an independent category of physical injury but as a contributing condition that elevates risks across these domains simultaneously.
The frequency of healthcare-associated infections varies substantially across resource settings. According to the WHO Global Report on Infection Prevention and Control, of every 100 acute-care inpatients, roughly seven in high-income countries and fifteen in low- and middle-income countries acquire at least one healthcare-associated infection during their hospital stay.
These infection rates are not fixed biological constants. In the United States, the Centers for Disease Control and Prevention (CDC) 2024 National and State Healthcare-Associated Infections Progress Report, published on July 15, 2026, tracked changes in national Standardized Infection Ratios (SIRs) across acute-care hospitals. An SIR compares the number of observed infections to the number predicted based on national baseline data, adjusting for facility types and patient risk factors.
Between 2023 and 2024, national SIRs declined: central line-associated bloodstream infections fell by 9 percent, catheter-associated urinary tract infections fell by 10 percent, and hospital-onset methicillin-resistant Staphylococcus aureus bacteremia fell by 7 percent. At the same time, the CDC report recorded an 8 percent increase in the national SIR for abdominal hysterectomy surgical site infections. These mixed data reflect observed national trends rather than conclusive proof of which specific interventions drove the changes. They show that while infection metrics can decline, progress remains uneven across surgical and clinical specialties.
III. When Treatment Creates an Infection
Human anatomy relies on specialized physical and physiological defenses. Intact skin, mucous membranes, respiratory cilia, gastric acid, and regular urinary flow help prevent environmental microbes from colonizing internal tissues. Modern medical care must frequently bypass these specific barriers to deliver life-saving treatment.
A central venous catheter illustrates how treatment creates a physical route for infection. Clinicians place central lines into major veins of the neck, chest, or arm to deliver essential fluids, chemotherapy, and vasopressors directly toward the heart. Once a line is in place, microorganisms can colonize it through two primary pathways: extraluminally, by migrating from the patient’s skin along the external surface of the catheter tract, or intraluminally, when bacteria contaminate catheter hubs during routine access.
Once microorganisms colonize a catheter, they can form a biofilm on its surface. Biofilms can make treatment more difficult through several mechanisms, including reduced penetration of certain antibiotics, altered bacterial metabolism and the survival of tolerant subpopulations. The importance of each mechanism varies by organism and antimicrobial agent; these forms of phenotypic tolerance differ from acquired genetic resistance. Because an infected catheter may remain a source of infection despite antimicrobial treatment, removal is sometimes necessary. IDSA guidelines particularly emphasize removal for infections involving pathogens such as Staphylococcus aureus, Pseudomonas aeruginosa and Candida species, while accounting for the patient’s need for vascular access.
Other invasive devices present distinct mechanical pathways for infection. An indwelling urinary catheter bypasses normal urethral flushing. Bacteria can ascend extraluminally along the mucous layer between the catheter and urethral wall, or migrate intraluminally through a contaminated drainage collection system. Positioning the drainage bag above the bladder can impede gravity drainage and increase the risk of contaminated urine flowing back toward the bladder.
Similarly, in mechanically ventilated patients, an endotracheal tube bypasses several normal upper-airway defenses and can impair effective clearance of secretions. Secretions can accumulate above the inflatable cuff, and microaspiration into the lower respiratory tract is one important pathway through which ventilator-associated pneumonia may develop.
Surgical incisions present a related vulnerability: operative procedures divide cutaneous defenses, exposing sterile underlying tissues to the patient’s endogenous flora or operating room air.
Pathogen persistence on hospital wards reflects two distinct pressures. First, heavy inpatient antibiotic exposure suppresses susceptible commensal flora, allowing resistant strains to colonize skin and mucous membranes.
Second, environmental survival depends on physical resilience. Standard quaternary ammonium disinfectants kill many vegetative bacteria but fail against bacterial endospores; consequently, Clostridioides difficile spores resist routine cleaning and require physical removal or dedicated sporicidal agents like sodium hypochlorite. Other pathogens, such as Acinetobacter baumannii, withstand desiccation for weeks on dry clinical surfaces.
According to the World Health Organization, systematic reviews indicate that comprehensive infection prevention and control programmes can prevent up to 70 percent of healthcare-associated infections. This is an estimate of prevention potential under effective infection-control practices, not a reduction that every hospital can automatically achieve. Achieving meaningful reductions requires continuous adherence to hand hygiene, strict aseptic insertion, and prompt removal of unnecessary invasive lines.
Preventing these infections is only the first challenge. Once a resistant organism enters the bloodstream, even timely recognition may leave clinicians with few effective treatment options.
IV. When an Infection Resists Treatment
When clinicians suspect a serious infection in a deteriorating inpatient, they assess the likely source, obtain appropriate diagnostic specimens, including blood cultures when indicated, and initiate empiric antimicrobial treatment according to the patient’s clinical condition. Culture results and susceptibility testing, when available, subsequently guide treatment refinement; the time required varies with the organism and testing method.
The clinical sequence shifts when laboratory sensitivities reveal a resistant pathogen. Decades of antimicrobial selection have generated multidrug-resistant bacteria, defined by international consensus criteria published by Magiorakos and colleagues as non-susceptibility to at least one agent in three or more antimicrobial categories. Extensively drug-resistant bacteria are non-susceptible to at least one agent in all but two or fewer antimicrobial categories, leaving susceptibility in at most one or two categories.
Inpatient wards manage bacterial challenges like carbapenem-resistant Enterobacterales and vancomycin-resistant Enterococcus, alongside resistant fungal threats such as Candida auris, an emerging yeast that often resists multiple antifungal classes and persists tenaciously on skin and equipment.
When an infection resists standard front-line therapy, clinicians face four interconnected challenges:
Initial empiric mismatch: The initial antibiotic regimen may lack activity against the infecting organism, delaying effective treatment until susceptibility results or other clinical evidence prompt a change.
Constrained therapeutic choices: Newer agents such as ceftazidime-avibactam or cefiderocol have activity against particular resistant gram-negative pathogens, but acquisition costs, formulary restrictions and organism-specific susceptibility may limit their use.
Toxicity of reserve antimicrobials: When appropriate alternatives are unavailable, clinicians may consider older agents such as polymyxins or aminoglycosides, weighing their potential effectiveness against nephrotoxicity and other serious adverse effects.
Operational demands of isolation: Contact precautions and appropriate patient placement help limit transmission but add protective-equipment procedures and nursing demands.
This clinical dilemma connects to the economics of antimicrobial development explored in a companion essay, The Antibiotic Paradox (forthcoming in this series): antibiotics reserved for limited indications may generate insufficient sales to offset high development costs. Uncertain returns and the need to preserve effectiveness can constrain investment in new treatments for resistant infections.
Preventing exposure becomes even more consequential for patients whose treatment has weakened their immune defenses.
V. Patients on the Edge: The Transplant and Immunosuppression Dilemma
The challenge of healthcare-associated infection becomes acute when medical therapy intentionally weakens a patient’s biological defenses. In solid-organ transplantation and oncology, preventing graft rejection or treating malignancy inherently lowers the barrier against opportunistic infection, even when hospital care is delivered without error.
Towana Looney’s documented treatment course illustrates this trade-off. As reported in clinical updates from NYU Langone Health, Towana Looney, a patient with end-stage renal disease, received a 10-gene-edited porcine kidney in November 2024 under an FDA expanded-access compassionate use protocol. The porcine graft functioned successfully for 130 days, providing dialysis-free renal clearance. In early 2025, Looney developed an infection that NYU Langone confirmed was unrelated to the porcine kidney. Her clinical team reduced her maintenance immunosuppression to assist her body in clearing the infection. Following that reduction, she subsequently developed acute graft rejection, requiring surgical removal of the porcine kidney on April 4, 2025, after which she returned to maintenance hemodialysis. Clinicians noted that the precise biological sequence precipitating the rejection remained under active investigation.
Importantly, Looney’s infection was never established as having originated from hospital care or institutional error. Her case illustrates the biological vulnerability of immunosuppressed patients rather than hospital negligence.
When severe infections emerge, clinicians must balance infection control against graft-rejection risk. Reducing immunosuppression may support infection control but can increase the risk of immune-mediated graft injury. Decisions depend on infection severity, time since transplantation, immunological risk and the patient’s treatment regimen. Strict aseptic insertion and device-maintenance protocols remain important defenses against preventable exposure.
VI. The Errors That Have Nothing to Do with Germs
Not every patient harmed by a hospital was ever near a pathogen. Many inpatient injuries stem from medication errors, diagnostic delays, and coordination breakdowns that occur in clean physical environments.
1. Medication Safety: Prescribing Versus Administration
Medication-related harm is among the most frequent causes of avoidable inpatient injury. The World Health Organization notes that medication errors contribute substantially to preventable healthcare injuries worldwide, with the WHO Global Patient Safety Challenge on Medication Safety estimating an annual global economic burden of $42 billion USD.
Preventing medication harm requires identifying where errors occur. In a 1995 prospective study, Bates and colleagues found that 56 percent of errors resulting in preventable adverse drug events occurred at the ordering stage, compared with 34 percent during administration. Errors were intercepted more frequently when they occurred earlier in the medication process: 48 percent at ordering, compared with none at administration. Because administration represents the final step in the medication delivery chain, errors that occur at the bedside are far less likely to be caught and frequently reach the patient directly.
High-alert medications, including concentrated electrolytes, intravenous insulin, unfractionated heparin, and parenteral opioids, carry an increased risk of serious patient harm when used incorrectly. Depending on the medication and the error, consequences can include dangerous electrolyte disturbances, severe hypoglycemia, major hemorrhage, or respiratory depression.
2. Diagnostic Delays and Cognitive Biases
Diagnostic errors can develop through cognitive mistakes, incomplete investigations, delayed test results and failures of communication. Unlike an immediately visible procedural mishap, some diagnostic failures accumulate over several encounters and become apparent only in retrospect.
The measured incidence of diagnostic error depends heavily on the clinical environment and research methodology. In an evidence review conducted for the Agency for Healthcare Research and Quality (AHRQ), researchers estimated that diagnostic errors occur in approximately 5.7 percent of emergency department visits. The authors emphasized that this figure was an extrapolation with explicit uncertainty, derived from three prospective studies in Canada, Spain, and Switzerland comprising 1,758 patients, rather than a directly measured national rate across all United States emergency departments.
In inpatient general medicine, retrospective medical record reviews have evaluated diagnostic contributions to adverse events. In the Harvard Medical Practice Study II, physician reviewers identified diagnostic mishaps among the categories of adverse events and examined their association with errors in management and negligence.
Diagnostic errors frequently stem from well-characterized cognitive heuristics. In anchoring bias, a clinician fixates on an initial diagnostic hypothesis and fails to adjust that assessment when conflicting clinical data emerges. In an illustrative hypothetical case, an elderly patient with known emphysema presents with sudden worsening dyspnea, and clinicians anchoring on an acute chronic obstructive pulmonary disease flare pursue bronchodilator therapy while delaying diagnostic evaluations for an acute pulmonary embolism.
Premature closure is a related but distinct failure: diagnostic inquiry stops once an initial explanation appears adequate, even when unresolved findings warrant further investigation.
3. Procedural Accidents and Handover Gaps
Procedural complications persist despite operative safety protocols. Surgical teams occasionally leave foreign bodies such as sponges inside wounds, or unintentionally injure adjacent nerves or vascular structures during complex dissections. Standardized operative time-outs and structured sponge-counting protocols serve as primary defenses against these physical errors.
Outside surgical suites, the transfer of clinical responsibility across shifts represents an ongoing systemic hazard. Modern duty-hour regulations and rotating shifts mean that an inpatient is handed off between clinical teams multiple times each day. During a rushed morning handover, a resident may omit an overnight decline in a patient’s urine output. Without a structured handover and an explicit action plan, the incoming team may not recognize the significance of that change until overt hypoperfusion develops.
VII. The Organizational Substrate: Staffing, Fatigue, and System Failure
The medication lapses, diagnostic blind spots, and communication failures detailed above rarely occur in a vacuum. When an adverse event happens, internal reviews historically sought an individual clinician to blame for a miscalculated dose or an overlooked vital sign.
Organizational theorist James Reason formulated the Swiss Cheese Model of accident causation to explain that catastrophic failures rarely stem from isolated human error. Harm occurs when multiple latent organizational defects, such as chronic understaffing, shift fatigue, unstandardized communication channels, and administrative pressure for rapid bed turnover, align simultaneously, opening a direct pathway for an error to reach the patient.
The Role of Bedside Nursing Surveillance
Registered nurses serve as the primary continuous surveillance system in acute-care hospitals. They assess neurological changes, track respiratory and hemodynamic trends, administer potent medications, and evaluate patient responses.
Kalisch and colleagues characterized missed nursing care as a patient-safety problem. Subsequent observational research has associated heavier nursing workloads with more care left undone and, in separate studies, higher postoperative mortality. Delayed bedside surveillance is one plausible mechanism connecting these findings, although the studies do not establish every step of that causal pathway. In a hypothetical comparison, a nurse caring for seven acute patients rather than four may have less time for repeated assessments, increasing the possibility that early signs of deterioration go unrecognized.
Empirical studies have measured the statistical relationship between nurse workloads and patient outcomes:
American surgical outcomes: In a 2002 JAMA study, Linda Aiken and colleagues examined 232,342 surgical patients across 168 non-federal adult general hospitals in Pennsylvania. After adjustment for patient and hospital characteristics, each additional patient per nurse was associated with a 7 percent increase in the odds of both 30-day mortality and failure to rescue, defined as death following a major complication. These were observational associations, not proof that a change in staffing alone would produce the same change in mortality.
European multicountry evaluation: In a separate observational study published in The Lancet in 2014, Aiken and colleagues evaluated 422,730 surgical patients across 300 hospitals in nine European countries and observed a similar adjusted odds ratio of 1.068 per additional patient in a nurse’s workload.
Staffing ratios are one measure of organizational pressure. Changes in hospital ownership offer another setting in which researchers have examined patient-safety outcomes.
Corporate restructuring and adverse events: In a 2023 JAMA study, Sneha Kannan, Joseph Bruch and Zirui Song compared 662,095 Medicare hospitalizations at 51 private equity-acquired hospitals with 4,160,720 hospitalizations at 259 matched control hospitals.
Following acquisition, the researchers found an adjusted difference of 4.6 additional hospital-acquired conditions per 10,000 hospitalizations, representing a 25.4 percent relative increase over the comparison group. The difference was driven primarily by central line-associated bloodstream infections and inpatient falls.
The observational study did not directly measure staffing changes or establish staffing reductions as the cause of the increased adverse-event rate.
VIII. The Economics of the Infection That Never Happened
Hospitals must fund the staff, equipment and preventive programmes that reduce avoidable harm, often before their financial benefits become visible.
In the United States, for participating acute-care hospitals and covered inpatient discharges under the Medicare Inpatient Prospective Payment System, payments are determined by Diagnosis-Related Groups (MS-DRGs). A hospital receives a predetermined payment for a specific clinical condition, regardless of the individual costs incurred during the stay.
However, complications do not automatically increase Medicare reimbursement. Under the CMS Hospital-Acquired Conditions and Present on Admission Indicator provision, designated conditions that were not present on admission generally cannot be used to assign a higher-paying MS-DRG when they would otherwise increase payment. Examples include certain catheter-associated urinary tract infections, vascular catheter infections and retained surgical items. Other qualifying diagnoses may independently affect the assigned payment category.
By contrast, preventive safety measures produce a different financial return. Many preventive activities do not generate separate reimbursement. Their value is realized through avoided complications, lower treatment costs and shorter hospital stays rather than additional revenue. The resulting savings depend on the hospital’s costs and reimbursement arrangements.
In a landmark meta-analysis published in JAMA Internal Medicine, Eyal Zimlichman and colleagues evaluated the costs of healthcare-associated infections, estimating that a single central line-associated bloodstream infection generates an average attributable hospital cost of $45,814 in direct expenses (measured in 2012 US dollars). Under prospective payment, these additional treatment costs can reduce a hospital’s operating margin, particularly when the complication does not qualify for additional reimbursement. The financial effect varies with the patient’s other diagnoses, the payment arrangement and the hospital’s actual costs.
Using that historical estimate solely as an illustration, preventing ten such infections would correspond to approximately $458,000 in avoided attributable treatment costs before accounting for prevention-programme expenditure, reimbursement and differences between hospitals. This is not an observed return on investment.
Financial incentives and the net fiscal impact of complications vary substantially across reimbursement structures:
Medicare: The financial consequences of complications depend on MS-DRG assignment, the Present on Admission payment provision and, separately, hospital-level performance under the HAC Reduction Program.
Commercial reimbursement: Payment arrangements vary by insurer and negotiated contract. Some reimburse additional hospital days or procedures, while others exclude payment for specified hospital-acquired conditions. The financial consequences depend on the contract and complication involved.
Capitated and value-based arrangements: Avoiding complications can reduce treatment costs and improve financial performance under some capitated and value-based contracts. The actual benefit depends on the contract, the costs avoided and which quality or readmission measures apply.
Successful prevention is difficult to measure because it produces an absence rather than an event, a challenge examined more broadly in a companion essay, The Preparedness Gap: Why the World Still Waits for Crises Before It Acts (forthcoming in this series). Low infection rates may reflect effective prevention, a reduced underlying risk, or both. Administrators therefore need evidence of reliable infection-control practices alongside clinical outcomes when deciding whether to maintain personnel, training, surveillance and equipment.
The Hospital-Acquired Condition Reduction Program applies a 1 percent payment reduction to applicable Medicare fee-for-service discharges at hospitals whose Total HAC Scores place them in the worst-performing quartile of hospitals covered by the programme. The score combines selected healthcare-associated infection measures and a claims-based patient-safety composite. This hospital-level penalty is separate from the claim-level Present on Admission provision.
The HAC Reduction Program makes selected safety outcomes financially consequential, although their effect on individual hospitals depends on payment exposure and operating conditions.
The implications extend beyond individual hospital wards. As emphasized in the WHO Global Report on Infection Prevention and Control, baseline routine infection control provides the frontline infrastructure required for broader epidemic preparedness. Facilities that underfund day-to-day infection-prevention capabilities cannot rapidly establish effective biocontainment when novel infectious threats emerge.
IX. What Safer Hospitals Actually Do
Hospitals have developed three complementary safeguards against the failures described above: infection-prevention bundles, technology-assisted verification and structured handovers with clinical escalation pathways.
1. Multifaceted Clinical Safety Initiatives
To address device-related infections such as central line sepsis, hospitals implement structured procedural bundles. The impact of systematic safeguards was demonstrated by Dr. Peter Pronovost and colleagues in the landmark Keystone ICU project in Michigan, published in the New England Journal of Medicine in 2006. Working across 103 adult intensive care units with complete reporting data (out of 108 enrolled) in a statewide collaborative cohort study, the initiative implemented a coordinated bundle centered on central venous catheter insertion: hand hygiene, chlorhexidine skin antisepsis, full-barrier sterile precautions, avoidance of the femoral vein, and daily evaluation of catheter necessity.
The intervention paired an evidence-based procedural checklist with a Comprehensive Unit-based Safety Program that fostered safety culture. As part of the participating units’ safety programme, bedside nurses were empowered to intervene when required sterile insertion practices were not followed.
In the published study, the mean rate of catheter-related bloodstream infections fell from 7.7 to 1.4 per 1,000 catheter-days between baseline and 16 to 18 months of follow-up. The adjusted incidence-rate ratio at 16 to 18 months was 0.34 (95 percent confidence interval, 0.23 to 0.50), equivalent to a 66 percent reduction relative to baseline. The median rate fell from 2.7 to zero within three months, although a zero median did not mean that every participating ICU remained infection-free. Because this was a statewide collaborative intervention without randomized assignment, the findings support the effectiveness of the combined safety programme but do not isolate the contribution of the insertion checklist from its accompanying organizational changes.
2. Technology-Assisted Medication and Diagnostic Safeguards
To intercept prescribing and administration mistakes before they reach the patient, hospitals rely on computerized verification systems:
Barcode medication administration (BCMA): When correctly implemented and used, BCMA checks scanned patient and medication identifiers against the electronic medication record, helping intercept identity and order-matching errors. It cannot independently determine whether a clinically valid order has become unsafe because the patient’s condition has changed.
Computerized Physician Order Entry (CPOE) with clinical decision support: Depending on system configuration, clinical-record integration and available patient data, electronic prescribing systems can check orders against documented allergies, relevant laboratory results and active medications. Appropriate alerts can help identify dangerous interactions or dosing errors, although excessive or irrelevant warnings may cause alert fatigue and frequent overrides.
Closed-loop diagnostic tracking: Computerized tracking systems facilitate timely communication by alerting clinicians to critical abnormal laboratory findings and urgent radiology reports. However, their real-world effectiveness depends on prompt clinical review, reliable routing, and clinician action.
3. Structured Handovers and Clinical Escalation Channels
To address shift-change communication breakdowns and unheeded clinical deterioration, hospitals have adopted standardized handover frameworks and rapid clinical escalation channels.
In a landmark 2014 study published in the New England Journal of Medicine, Amy Starmer and colleagues evaluated the I-PASS handover curriculum, an acronym for Illness severity, Patient summary, Action list, Situation awareness and contingency planning, and Synthesis by receiver. Across nine pediatric residency programs, the intervention combined structured verbal and written communication formats with interactive workshops, faculty observation, and process integration.
Across the nine participating pediatric residency programmes, medical errors fell by 23 percent, from 24.5 to 18.8 per 100 admissions. Preventable adverse events fell by 30 percent, from 4.7 to 3.3 per 100 admissions. Statistically significant reductions in medical errors occurred at six of the nine sites, without a significant increase in handover duration. The findings support structured handover programmes, although results in other settings depend on implementation and sustained clinical adoption.
Rapid Response Teams traditionally bring critical care expertise to general inpatient beds when bedside nurses, physicians, or allied staff detect early signs of physiological decline based on objective vital-sign criteria. In response to bedside warnings going unheeded, institutions developed separate family escalation pathways. The University of Pittsburgh Medical Center established Condition Help to enable patients and families to call an urgent evaluation team directly. In parallel, the Josie King Foundation advocated for family-activated rapid response mechanisms across hospitals, giving bedside concerns an established route to clinical review.
These safeguards operate at different points in the care process. Sterile insertion practices reduce exposure to infection, barcode systems intercept selected medication errors, and structured handovers preserve information as responsibility changes. Each depends on consistent use and timely action when a problem is identified.
X. The Hospital That Prevents the Next Patient from Getting Sick
Hospitals perform extraordinary work, from repairing catastrophic injuries to sustaining premature infants and treating complex cancers. Yet sophisticated care can be undermined by failures of basic patient protection: a preventable line infection, an unreviewed laboratory result or a warning that never triggers clinical action.
The story of Josie King endures because it captures the human consequences of operational failure: at one of the world’s most prominent academic medical centers, her mother’s repeated warnings about her daughter’s deterioration failed to trigger an effective clinical response. That failure prompted Sorrel King to establish the Josie King Foundation to advocate for family empowerment and clinical escalation channels. While technical bundles and electronic safeguards address specific procedural risks, family-activated escalation addresses the core breakdown of Josie’s case: an alarm with nowhere established to go.
A safer hospital gives concerns the power to change care. Its staff have the time and support to recognize deterioration, its handovers preserve information that must not be lost, and its patients and families have a route to urgent review when ordinary communication fails. Josie’s story remains a test of whether those safeguards work when they are needed most.
Primary References
Johns Hopkins Medicine. No Room for Error. Published January 8, 2016. Available at: https://www.hopkinsmedicine.org/news/articles/2016/01/no-room-for-error. See also: King S. Josie’s Story: A Mother’s Inspiring Crusade to Make Medical Care Safe. New York: Grove Atlantic; 2009.
World Health Organization. Patient Safety Fact Sheet. Geneva: World Health Organization; 2023. Available at: https://www.who.int/news-room/fact-sheets/detail/patient-safety
World Health Organization. Global Report on Infection Prevention and Control. Geneva: World Health Organization; 2022. Available at: https://www.who.int/publications/i/item/9789240051164
World Health Organization. Medication Without Harm: WHO Global Patient Safety Challenge. Geneva: World Health Organization; 2017. Available at: https://www.who.int/initiatives/medication-without-harm
Centers for Disease Control and Prevention. 2024 National and State Healthcare-Associated Infections Progress Report. Atlanta, GA: U.S. Department of Health and Human Services, CDC; published July 2026. Available at: https://www.cdc.gov/healthcare-associated-infections/php/data/progress-report.html
Donlan RM. Biofilms and Device-Associated Infections. Emerging Infectious Diseases. 2001; 7(2):277-281. Available at: https://wwwnc.cdc.gov/eid/article/7/2/70-0277_article
Magiorakos AP, Srinivasan A, Carey RB, et al. Multidrug-resistant, extensively drug-resistant and pandrug-resistant bacteria: an international expert proposal for interim standard definitions for acquired resistance. Clinical Microbiology and Infection. 2012; 18(3):268-281. Available at: https://onlinelibrary.wiley.com/doi/10.1111/j.1469-0691.2011.03570.x
Mermel LA, Allon M, Bouza E, et al. Clinical Practice Guidelines for the Diagnosis and Management of Intravascular Catheter-Related Infection: 2009 Update by the Infectious Diseases Society of America. Clinical Infectious Diseases. 2009; 49(1):1-45. Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC4039170
Pronovost P, Needham D, Berenholtz S, et al. An Intervention to Decrease Catheter-Related Bloodstream Infections in the ICU. New England Journal of Medicine. 2006; 355(26):2725-2732. Available at: https://www.nejm.org/doi/full/10.1056/NEJMoa061115
Starmer AJ, Spector ND, Srivastava R, et al. Changes in Medical Errors after Implementation of a Handoff Program. New England Journal of Medicine. 2014; 371(19):1803-1812. Available at: https://www.nejm.org/doi/full/10.1056/NEJMsa1405556
Kannan S, Bruch JD, Song Z. Changes in Hospital Adverse Events and Patient Outcomes Associated With Private Equity Acquisition. JAMA. 2023; 330(24):2365-2375. Available at: https://jamanetwork.com/journals/jama/fullarticle/2813379
Aiken LH, Clarke SP, Sloane DM, Sochalski J, Silber JH. Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction. JAMA. 2002; 288(16):1987-1993. Available at: https://jamanetwork.com/journals/jama/fullarticle/195438
Aiken LH, Sloane DM, Bruyneel L, et al. Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study. Lancet. 2014; 383(9931):1824-1830. Available at: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(13)62631-8/fulltext
Ball JE, Murrells T, Rafferty AM, Morrow E, Griffiths P. ‘Care left undone’ during nursing shifts: associations with workload and perceived quality of care. BMJ Quality & Safety. 2014; 23(2):116-125. Available at: https://qualitysafety.bmj.com/content/23/2/116
Bates DW, Cullen DJ, Laird N, et al. Incidence of Adverse Drug Events and Potential Adverse Drug Events: Implications for Prevention. JAMA. 1995; 274(1):29-34. Available at: https://jamanetwork.com/journals/jama/article-abstract/389136
Brennan TA, Leape LL, Laird NM, et al. Incidence of Adverse Events and Negligence in Hospitalized Patients: Results of the Harvard Medical Practice Study I. New England Journal of Medicine. 1991; 324(6):370-376. Available at: https://www.nejm.org/doi/full/10.1056/NEJM199102073240604
Leape LL, Brennan TA, Laird N, et al. The Nature of Adverse Events in Hospitalized Patients: Results of the Harvard Medical Practice Study II. New England Journal of Medicine. 1991; 324(6):377-384. Available at: https://www.nejm.org/doi/full/10.1056/NEJM199102073240605
Agency for Healthcare Research and Quality. Diagnostic Errors in the Emergency Department: A Systematic Review. Comparative Effectiveness Review No. 258. Rockville, MD: AHRQ; 2022. Available at: https://effectivehealthcare.ahrq.gov/products/diagnostic-errors-emergency/research
Zimlichman E, Henderson D, Tamir O, et al. Health Care-Associated Infections: A Meta-analysis of Costs and Financial Impact on the US Health Care System. JAMA Internal Medicine. 2013; 173(22):2039-2046. Available at: https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1733452
Kalisch BJ, Landstrom GL, Hinshaw AS. Missed Nursing Care: A Concept Analysis. Journal of Advanced Nursing. 2009; 65(7):1509-1517. Available at: https://onlinelibrary.wiley.com/doi/10.1111/j.1365-2648.2009.05027.x
Reason J. Human error: models and management. BMJ. 2000; 320(7237):768-770. Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC1117770/
UPMC Children’s Hospital of Pittsburgh. Condition Help. Available at: https://www.chp.edu/about/patient-safety/initiatives/condition-help
Centers for Medicare & Medicaid Services. Hospital-Acquired Condition (HAC) Reduction Program. Baltimore, MD: CMS. Available at: https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/value-based-programs/hac/hospital-acquired-conditions
Centers for Medicare & Medicaid Services. Hospital-Acquired Conditions and Present on Admission Indicator Reporting Provision. Baltimore, MD: CMS. Available at: https://www.cms.gov/medicare/payment/hospital-acquired-conditions-hac
NYU Langone Health. Pig Kidney Recipient Returns Home After Transplant Breakthrough at NYU Langone Health. New York, NY: NYU Langone NewsHub; published February 25, 2025, updated April 11, 2025. Available at: https://nyulangone.org/news/pig-kidney-recipient-returns-home-after-transplant-breakthrough-nyu-langone-health
