In this installment of Building Bridges in Infection Prevention, what a mattress mistake can cost both patient and facility.
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Infection Control Today®’s Building Bridges in Infection Prevention series features infection prevention and control professionals at all levels speaking with each other, giving best practices, and telling stories of what has worked—and not worked—for them in their facilities.
Do you have a best practice to share? A question you need answering? Or have an answer to the weekly question? If so, please send them to tmartonicz@mjhlifesciences.com and help others in the IPC community.
Several years ago, I got a call I’ll never forget.
A patient had just been admitted into an emergency department (ED) bay and noticed fresh blood on the sheet beneath them. The nurse did what many would do: They changed the linen and moved on. But no one looked further. No one questioned the integrity of the surface below.
No one noticed the small tear in the stretcher mattress.
The truth came out only after the mattress began “bleeding” again, but this time from within.
The previous patient had suffered a GI (gastrointestinal) bleed. Somewhere along the way, that biohazard had worked its way through a compromised mattress cover. And when the stretcher was “cleaned,” the tear was missed. It was just wiped down on the surface, the way it always is.
Eventually, an ED technician was told to remove the mattress, and that’s when a bad situation became catastrophic.
The technician removed the cover (thankfully) but then threw the contaminated mattress into an open-top C&D (construction and demolition) dumpster outside the facility. It was snowing. The mattress became soaked. The entire dumpster, by regulation, was now contaminated and treated as regulated medical waste.
The cleanup cost thousands. But the real cost was deeper.
This Is Not a One-Off Mistake
After this incident, I became almost obsessive about mattresses—checking them constantly, auditing stretchers, and inspecting covers. Eventually, bed management was added to my responsibilities.
What I learned confirmed what I had already suspected:
This is a widespread, systemic issue in health care.
Tears in mattresses are frequently overlooked by environmental services (EVS) and nursing alike. Even when someone does report the damage, the most common response is: “We don’t have the budget to replace it right now.”
That’s unacceptable.
Yes, full mattress replacements are expensive, but so is contamination. So is patient harm. So is a $10,000 cleanup. Lower-cost options such as CleanPatch or specialized toppers can safely extend a mattress's lifespan, but only when used correctly.
If body fluids or cleaning chemicals have already infiltrated the foam, it is too late. You cannot patch what has already been compromised.
The Real Issue? Culture and Accountability
This wasn’t just a technical failure; it was a cultural one: a lack of attention, a lack of urgency, and a normalization of risk.
Too often, mattress integrity is not on anyone’s checklist. It’s not documented. It’s not talked about. But it should be because a torn mattress is a direct line to cross-contamination.
Patients deserve better. Staff deserve better. Health care systems should not tolerate risk that is this visible and this preventable.
What You Can Do Right Now:
It’s Time to Invest in Safety—and Enforce It
Patient safety is not a line item; it is a promise. And that promise extends to every surface a patient touches.
We cannot continue to ignore damaged mattresses and call ourselves compliant. We cannot let “budget constraints” excuse preventable harm. And we absolutely cannot allow a culture where reporting damage is seen as optional or inconvenient.
If we want to prevent the next $10,000 mistake, we must fix the tear before it bleeds through.
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