Identifying Root Causes and Mitigation Strategies for Sepsis Occurring in Hospitals
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By
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Fizza Manzoor
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Michael Klompas
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Saranya Seetharaman
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Christina Chan
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Chanu Rhee
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September 17, 2026
Clinical Scorecard: Identifying Root Causes and Mitigation Strategies for Sepsis Occurring in Hospitals
At a Glance
| Category | Detail |
|---|
| Condition | Hospital-onset sepsis |
| Key Mechanisms | Infections and noninfectious conditions leading to acute organ dysfunction |
| Target Population | Adults aged 18 years or older admitted to acute care hospitals |
| Care Setting | Acute care hospitals |
Key Highlights
- Hospital-onset sepsis occurred in 5212 of 558,037 admissions (0.9%)
- Respiratory infections accounted for 56% of sepsis events
- 31% of infection-related sepsis cases were classified as potentially preventable
- Key opportunities for prevention included improving infection management and NV-HAP prevention
- Noninfectious conditions accounted for 21% of hospital-onset sepsis events
Guideline-Based Recommendations
Diagnosis
- Use CDC Adult Sepsis Event criteria for identification
Management
- Enhance treatment of recognized infections to prevent progression to sepsis
- Implement strategies to prevent nonventilator hospital-acquired pneumonia (NV-HAP)
Monitoring & Follow-up
- Conduct detailed medical record reviews to assess infection sources and preventability
Risks
- Consider intrinsic patient risks and extrinsic healthcare-related factors in preventability assessments
Patient & Prescribing Data
Antibiotics were administered in all cases, often for 4 or more days, even in noninfectious events.
Clinical Best Practices
- Improve early infection management and subspecialty consultations.
- Enhance control of emesis, constipation, urinary retention, and volume status.
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