SAFER HOSPITALS A xx B xx
The opportunities to improve patient safety are substantial. For example, a recent report on ward-based decontamination of medical equipment found that healthcare-associated infections could potentially be reduced by up to 35 per cent.3 There are much-needed requirements for innovation as well as improving existing designs. This is likely to be best achieved by having an interface with manufacturers so that they can get important feedback on what works and does not work as well as areas where currently there are no solutions and innovation is required. England therefore has the opportunity to build some of
the safest hospitals in the world. If implemented correctly, improvements in design and practice could significantly enhance patient outcomes while simultaneously helping to preserve the effectiveness of antibiotics for the future. It is also important to recognise that many of the concepts that would improve patient safety would not increase costs. On the contrary, they could reduce costs across the entire project lifecycle and continue to generate savings during the operational life of the building. This will be discussed later.
A: Unforeseen issues (hazards) may occur at any stage and are expensive to rectify.
B: By identifying issues at inception of a project, mitigations can be put in place, so there should be no unexpected expensive issues downstream which delay projects.
true cost of infections originating from the built environment is likely to become increasingly apparent. Antimicrobials can no longer serve as a temporary solution for deficiencies in design, construction, installation, or commissioning. While there is readily available data to assess the
safety of a new car, surprisingly there are no widely accepted metrics to evaluate the safety of one hospital design compared with another especially with respect to measuring infections acquired in hospitals directly due to deficiencies in design of its built environment. This raises an important question: how can we determine whether evolving hospital designs are genuinely improving safety? Furthermore, from the perspective of design, construction, installation, and commissioning teams, a lack of awareness of the risks to patient safety can create the false assumption that everything is functioning appropriately – when this may be far from the truth (see Case Study boxout below).
The potentially good news Despite these challenges, there are reasons for optimism. A growing understanding of risks originating from the built environment provides an opportunity to design hospitals from the outset in ways that reduce both the transmission of infection and the development and spread of AMR.
Case study
Following the opening of a large new English hospital with 100 per cent single room occupancy and associated en suite, it was reported back that there were no issues with the water system. Shortly afterwards, the site was visited by an expert in water and wastewater safety which identified numerous risks relating to the periphery of the water and wastewater system and the main wastewater systems. The risks included oversupply of clinical hand wash stations leading to stagnation, incorrect placement posing a risk to patient safety, blockages of the main sewerage stack as well as blocking of the horizontal wastewater systems and several wards due to placement of mostly sandwich wrappers and drink bottles which would likely to have occurred during the construction and installation phase. The initial report had been undertaken by individuals without the necessary
expertise and was likely to be based on the finding that so far there had been no uncovered issues relating to Legionella or pseudomonas with the water system. It is essential that water/wastewater systems are now divided into three areas and that only individuals with the necessary competence utilised in any work/ review of these areas.
36 Health Estate Journal April 2026
New build issues Significant and costly issues affecting patient safety in new healthcare facilities might appear to be a relatively recent phenomenon. Examples include problems at the new Queen Elizabeth University Hospital in Glasgow, delays in the opening of the new hospital in Edinburgh, elevated microbial levels in the water systems of the new Royal Papworth Hospital associated with patient infections, and issues affecting the new maternity hospital in Belfast. In the latter case, the hospital did not open because of widespread overgrowth of the water systems with Pseudomonas aeruginosa. However, these issues are not new. A report examining
the early Private Finance Initiative (PFI) hospitals constructed shortly after the start of the new millennium revealed numerous problems. While some were unique to individual sites, many were repeated across multiple new hospitals. Furthermore, numerous other projects – both new builds and refurbishments across the NHS – have experienced significant and costly issues affecting patient safety. Broadly speaking, two fundamental problems must be addressed if we are to deliver safer hospitals: 1. Delivery assurance: Even when the correct requirements are identified at the inception of a project, there is no guarantee that they will be delivered safely when the building opens. There is currently no robust process to ensure that what is envisioned during planning is actually delivered in practice.
2. Failure to adopt emerging risk mitigations: New risks to patient safety arising from the built environment have been identified for more than a decade, yet the necessary mitigations have not become mainstream practice. This includes risks associated with wastewater systems, many of which were identified through research into AMR.
Additionally, certain historical practices – which were allowed to persist largely because there was insufficient evidence demonstrating harm – are now being challenged, particularly where they conflict with fundamental infection control and decontamination principles.
Front-loading projects Unforeseen issues during construction projects can arise at any stage. The later such issues are identified, the more costly they become to rectify. In some cases, problems are only discovered once the building is occupied by patients,
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