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Safety and Justice/Consequences 6/Outbreak
From SKYbrary Wiki
The Maasstad Hospital at Rotterdam in the Netherlands experienced an outbreak of a nasty bacterium. The Klebsiellabacterium was first found in October 2010. Only late May of 2011 the hospital board admitted that there was a problem, took action and alerted neighbouring hospitals. Of the 115 infected patients 28 died. In three of these cases the infection was very likely the cause of death.
In a special report, the Healthcare Inspectorate in the Netherlands said: "Especially the medical microbiologists have a heavy responsibility to ensure effective infection prevention and intervene when necessary. The Inspectorate found that they did not act as expected […]. All medical microbiologists were aware of the Klebsiella outbreak but did not respond adequately to the increasing number of infected patients. They neglected to take action which should have been their responsibility and sought insufficient help from above and from outside."
This can be seen as a deliberate violation of a rule: the rule was clear, people did not think it was necessary to act.