Death, Birth, Money, and Diversity: A Q&A With the Author of Hospital

Julie Salamon‘s new book, Hospital, chronicles a year in the life of the Maimonides Medical Center in Brooklyn, N.Y. She begins with two quotations that for me, having spent enough time in the E.R. as a volunteer rape-crisis counselor, resonate strongly.

HospitalJulie Salamon

The first is the Oath of Maimonides, a Jewish physician and philosopher.

The second is a quote from the film The Hospital:

“… a man comes into a hospital in perfect health … In the space of one week we chop out a kidney, damage another, reduce him to coma, and damn near kill him.”

Salamon’s book provides a vivid snapshot of the effects of the U.S. health-care system, where “cancer is a growth industry” and where first-year residents learn that Occam’s razor doesn’t apply to medicine.

Salamon is a bestselling author whose work has appeared in The New York Times, The Wall Street Journal, Vanity Fair, and The New Yorker, among others. Her previous books include The Devil’s Candy, The Net of Dreams, and Rambam’s Ladder, the last of which led directly to the writing of Hospital.

Before she answers our questions about her book, Salamon would like to ask a question of Freakonomics readers:

What has been your most memorable hospital experience — heartwarming or horrific — and what did it tell you about what works/what is broken in our health care system?

Post your answers and comments below.

Q: What have politicians said about health care reform that’s most accurate in light of the real-life situation you witnessed at Maimonides and where are they most off?

A: The politicians who acknowledge that the system is a mess and needs to be fixed are accurate. Certainly both Obama and Clinton recognized the need for universal health coverage. But that’s only the beginning. Look at the problems in Massachusetts, which has provided universal coverage without providing incentives to encourage people to go into primary care medicine — or without putting strong insurance regulation into place.

Well, I could go on and on about this, but here are my headline thoughts:

Medical and nursing education subsidized so our medical corps don’t enter the work force saddled with large debt. We need to entirely change the malpractice system. We need to encourage better health through prevention rather than procedures and medication.

It is time to make health care less of an industry and more of a national priority. Wouldn’t it be nice if the first thing your doctor’s receptionist asked you was, “What’s wrong with you?” rather than “What kind of insurance do you have?”

INSERT DESCRIPTIONPam Brier, president and CEO of Maimonedes.

Q: How can the minimally paid cleaning staff and technicians at a hospital affect patient health?

A: Hugely. A few years ago the Institute of Health, which advises the federal government on medical matters, reported that a remarkable number of medical people in hospitals failed to regularly wash their hands. So now it isn’t unusual to go to a major medical center and find doctors wearing signs around their necks: “Ask me if I washed my hands.”

Dirty floors can also carry dangerous bacteria and the people responsible for the important job of keeping them clean are often the lowest paid employees.

Q: Which hospital’s emergency room would you go to if you had your choice of any in New York? Which would you avoid at all costs?

A: Right now I would probably want to go to the Maimonides emergency room simply because I know so many people there! Without a doubt, knowing someone on the inside helps a lot at any hospital. But more often than not, you don’t have much choice when it’s a true emergency; you’ll end up at the closest place to wherever you happen to be.

So a couple of pieces of advice: If you take any medication or have any allergies, keep a typed list with you at all times. Clear information is your best friend. Your second best friend is your actual best friend. It’s always better to have someone who can be your ally and protector.

MaimonidesA community dinner at Maimonides Medical Center.

Q: The Jewish community has a huge sway over Maimonides and the way it’s operated. How are they able to hold their influence at Maimonides? Did this influence quality of care for non-Jewish patients?

A: While I was at Maimonides I met this amazing, tiny elderly woman named Miriam Lubling who was an immigrant nursery-school teacher — not a wealthy person. Yet she had become an associate trustee at New York University Medical Center because she referred so many Jewish patients to N.Y.U. from Borough Park in Brooklyn.

While other hospitals in New York try to cater to the city’s large Jewish population, Maimonides has a special relationship with the Jewish community. It was founded as a Jewish hospital and remains kosher. There is a “Sabbath elevator,” which stops at every floor so Jewish patients and visitors don’t have to push buttons on the Sabbath in violation of religious law. There is even a light that goes on to alert Cohanim — descendents of priests — that someone has died because the Cohanim are not supposed to be in the presence of the dead. Hatzolah, the Jewish ambulance corps, has influence in the emergency room; while I was there Hatzolah members vetoed the hiring of a nursing director they didn’t like.

Now, however, the majority of Maimonides patients come from all different cultures and ethnic groups (the hospital claims 67 languages are spoken there). The hospital does considerable outreach. I accompanied the hospital president to a mosque where she talked to Pakistanis about getting colonoscopies. Every month the hospital invites pregnant Chinese women to attend seminars in Chinese on pre-natal care (and the kosher kitchen has a Chinese menu). Thirty patient representatives speaking numerous languages help with interpretation. That’s what I meant in the subtitle of my book by “Diversity on Steroids!”

Q: How important to a hospital is the support of the community around it?

A: Remember that old expression, “pillar of the community”? Hospitals are supposed to be one of those. For most hospitals, community support is crucial — except for rarefied specialized hospitals that deliberately cater to national or international patients.

In New Orleans, because of divisive politics, the hospital system still hasn’t recovered from the devastation of Hurricane Katrina. In addition to humanitarian reasons, hospitals that want to succeed financially have to understand and cultivate their communities.

Q: In the book, a surgeon speaks about the bell curve of performance between different departments and teams — with some of them having exceptional outcomes, others with disturbingly poor patient results, and a large middle-ground. What does this mean for patients and why does this curve exist?

A: I first heard about the medical bell curve in a fascinating article Atul Gawande wrote in The New Yorker.

Only in recent years have companies like HealthGrades started measuring outcomes. But statistics only tell part of the story. What kinds of patients does a doctor or hospital treat? How much does the relationship between patient and doctor matter? What about location? Is it worth traveling across the country for treatment because a doctor has better outcomes? There are no easy answers.

As the medical director at Maimonides asked me, “What are the right statistics to use for outcomes? You treat a patient for pneumonia, and they go home and have a horrible course … the patients survive, so the mortality figures don’t look that bad.”

The curve exists because doctors are people and hospitals are places run by people, some of whom are smarter, more talented, and sometimes shrewder about gaming the system. Individual patients should make sure their doctors aren’t at the low end of the curve. After that, they have to take into consideration many factors.

Q: How does the way a hospital treats the uninsured affect operations and the care the insured are getting?

A: At Maimonides I saw constant tension between efforts to provide hospital care for the entire community and the desire to make enough money to be in the black.

That means for non-emergency care, such as elective surgery or cancer treatment, most uninsured patients would be referred to a public hospital. Yet many uninsured patients enter the hospital through the emergency room and stay a long time. I met one such patient whose bill exceeded $1 million — that would never be paid. The insured are affected by the money pressure this puts on the system.

Q: What was the biggest financial threat to the hospital?

A: The inequitable and convoluted reimbursement system.

Q: How do pharmaceuticals and insurance companies affect hospitals? How do individual doctors deal with this relationship? Is the relationship changing?

A: Enormous impact. The pharmaceutical companies are intertwined with hospitals and doctors, in positive and negative ways.

The drug companies sponsor seminars, introduce new medicines, do research, and sometimes provide free drugs for uninsured patients. But those same companies have a vested interest in determining which studies are supported, which diseases get attention, and which populations are served.

Some doctors and hospitals try to maintain objectivity by limiting the access of pharmaceutical sales people. Many have stopped allowing the drug companies to buy lunch for their staffs.

The relationship with insurance companies is even more fraught. I have yet to meet a doctor, nurse, or hospital official who has anything good to say about the current situation.

Q: What’s the first thing a hospital usually relies on to help bail them out of financial difficulties?

A: Judging from many hospitals, bankruptcy court. The lucky ones — the big prestigious academic centers — can turn to philanthropy.

Q: You write that whenever a patient is discharged the hospital saves at least $10,000. What incentives are used to get patients to leave sooner and how well do they work?

A: The main incentive is having a good discharge plan in place. So if the patient needs rehab or extended nursing care following surgery, for example, the hospital can help find a place or person who accepts that patient’s insurance and is available. This is very effective.

Problems arise when the patient is uninsured or has poor insurance. This makes it difficult to discharge the patient safely because there is nowhere for the patient to go. Universal health coverage would be very effective in solving this problem.

Q: You mentioned that cancer is a growth industry … what other industries bring in a lot of money for hospitals?

A: Lucrative areas are cardiac angioplasty, knee and hip replacements, and imaging (MRI/CAT scans). These are areas that certain insurers are willing to pay large amounts for. I don’t know exactly how this came to be, but now I am going to try and find out!

Q: As malpractice costs for private physicians rise, what has this done to a hospital’s staff of physicians?

A: Though rising malpractice costs hurt a hospital’s bottom line, there are some benefits — if you like silver linings! Many talented doctors opt to work for a hospital rather than private practice because the hospital picks up the malpractice tab.


I'm British and live in fear that I should ever have to travel to the US, in case I should fall ill. The injustice of a system based upon the ability to pay thousands of dollars (for something that may have been completely unforeseen and outside of my control) just strikes me as barbaric.

Give me the National Health Service any day, with it's minor problems with keeping access fair across the entire country.


Residents are just trying to survive. "billables" isn't a word they even know.


I got admitted to the ER in a certain East Side hospital a few years ago for head trauma. I waited 3 or 4 hours to get stapled up and then get into the MRI room for a quick check for skull fractures (there were none). Pretty standard, really.

It's important to note, though, that I had just completed a 6-mile run when I got assaulted on the street and had to be put in the ambulance. For the first 2 hours in the ER, I felt dehydrated or at least THIRSTY and repeatedly asked for water and finally (after 2 hours) got a small cup. For the next hour or two, I repeatedly asked for food, and/or something for the pain. I was famished and rather weak from the running, injury, stress of the situation, and not having eaten in 8 hours. Finally, after 3 or 4 hours in the ER, a nurse offered to get me a soda out of the vending machine in the nurses lounge. How sweet! She waited for me to hand over the buck. I asked for something with sugar but no caffeine and was brought a Mountain Dew. I washed it down with two Tylenol and went out to find a cab home.

It is really too much to give patients WATER, and maybe a granola bar or something?!



As a fifteen year hospital administrator a horrific hospital experience is dealing with an

MD with an MBA.

Peter Helmberger

Hey Julie,

Back when I taught economics, I believed, and still do, that markets are wonderful devices for achieving economic efficiency providing buyers and sellers were fairly numerous and well informed about what they were buying and selling. In the health care industry, buyers often haven't a clue what they need. It's absurd to suppose a market mechanism will work under these circumstances. What do you think?

John Pinkerton

I had a midnight surgery for an emergency appendectomy at age 17 and spent 10 days in a British hospital in southern England in 1963. Not quite 40 years later in 2002 (age 56) I had a radical prostectomy to remove my cancerous prostate and I spent three and a half days in a HMO hospital in northern California. It’s a no-brainer. The 10 days in a British hospital gets a 9 out of 10 (one point off as the ward TV was b&w) and the three days in the HMO hospital in NorCal gets a very generous 4 out of 10.

The 1963 experience clearly outclassed the 2002 experience? I was in a 20 bed men’s surgical ward in England. It was clean, bright and nearly immaculate. Clean starched sheets every second day. Five nurses and three candy striper assistances worked in our ward and were always available, if needed. We (the patients) played card games, talked about how we were doing and many told life experience stories (best were from the Peter Lorre look-alike who’s wife tried to do him in with a hatchet but he had a hard head and the blow just took off part of his skull. Second was the classic retired military British officer who had served in India and had met Gandhi.). After four days I was assigned by the head nurse to push the trolley around at 7 PM to each bed offering tea, coffee, hot chocolate or Bovril. This was done to (1) force me to exercise a bit every day and (2) to stop me from feeling sorry for myself. The entire atmosphere there was one of teamwork and comradeship. The best way to relate it to the reader is that it was similar to when I played team sports in high school or college. Wonderful atmosphere. Doctors were friendly and took their time with you. As the only Yank in the place I welcomed it as a chance to get to know other patients and a different way of being treated (best story: I was prepped for surgery by a 16 year old candy-striper and the young lady, of all things, just happened to live on the same street as me. She was so embarrassed. I was too, a bit, but I was in quite a bit of pain so I put a towel over my face to give her some privacy and to lessen the risk of losing an important part of my anatomy). The food was pretty good, too. After that stay I was never afraid of going into a hospital.

That is until my prostate cancer. I had my own room at the HMO but it could have double as a storage closet. The dust bunnies under my bed and in the corners were there for my entire stay (it was to be five days but I made such a fuss to get out they let me out after three and a half days). The nurse spilled part of my catheter bag of urine at the foot of my bed and used a paper towel to wipe it up. It was never mopped up or sanitized. I also caught a toenail fungus on my right big toe. The nurses always seemed tired, overworked and almost always in a hurry. The food, well, all I say is that I wouldn’t have donated it to homeless shelter. The best experience was getting prepped for surgery. Everyone was cheerful and upbeat. A good tactic to keep the patient distracted and from becoming too scared about the upcoming surgery. An experience I hope to never repeat.


Deanna McNeil

My colleague at work was days away from giving birth to her child and realized one morning that she couldn't feel the baby moving. Hours later it was born with the cord wrapped around the neck, stillborn. What the staff did next was, for all of us, amazing. That dear little girl was washed, dressed in an exquisite donated dress, wrapped in a hand made crocheted blanket, photographed, fingerprinted for her birth certificate and whatever memorabilia that related to this childs birth were placed in a special container for the family. The photos were placed in an album.

There were no doubt other things that the staff did that are private and I wouldn't know about but to this day I have never forgotten that child and thought so well of a hospital. My work colleague? She successfully gave birth the following year to another gorgeous little girl who lights up a room with her delightful smile.



#5 This week Britain celebrates 60 years of free socialized medicine....

Guy in Chicago

What a difference location makes:

I live in a gentrifying neighborhood in Chicago. I woke up one morning with what turned out to be a kidney stone slowly inching its way through the ureter. Clueless, scared, vomiting from pain and wearing pajamas completely soaked with sweat, I called 911.

Apparently, I looked like a suffering drug addict of some sort. The Chicago Fire Dept. ambulance guys smirked at me when they arrived. Then, when we got to the hospital -- a bad hospital in a tough neighborhood -- I got zero pain meds. Sometime after screaming subsided into moaning, they eventually gave me ibuprofen, which helped.

A week later, I talked to an emergency doc who works in Naperville, a rich suburb. When I described the situation, he said they clearly thought I was drug seeking. If he had seen me in Naperville, he said, they would have immediately treated the pain.

I understand how difficult it is for nurses and emergency docs to determine who is drug seeking to satisfy an addiction and who isn't. But this is an example of skepticism impeding decent care. And the poor get the worst of it.

(To top it off, I ended up owing a trivial amount of my bill. I never got the statement and they sent it to collections. And now they refuse to take it off even though it was clearly a mistake (theirs!) and I paid as soon as I heard of the debt. Great care overall!)



Occam's razor: I showed up at the ER when I was twenty years old, with urgency, frequency, and burning with (slightly blood-tinged) urination. (Classic cystitis, the most common UTI, incredibly common--a clever chimp could have diagnosed it.) The resident DID NOT inquire into my sexual activity, method of birth control, water intake, etc.: he ran a $500 test for lupus, ran no urinalysis, and sent me home with Naproxen. He didn't even recommend cranberry juice.

Two years ago my husband woke up with one side of his face paralyzed. We waited two hours in an ER that was virtually empty before being seen; then the doc ordered an MRI. Nothing on that MRI or on the subsequent MRI. Found out later there is a simple, failsafe, sugar-on-the-tongue test--30 seconds--for an essentially benign condition called Bell's palsy, which turned out to be the source of the problem. The doctor could have done it in five minutes and saved us several hours' worry and our insurance co. several thousand dollars.

These guys aren't practicing 'defensive medicine' --they have their eyes on their billables.



C.W. Bill Young Department of Defense Marrow Donor Program. Best experience I ever had, great staff, great prep, great follow through. Everyone was very kind, infromation flowed, and they made it possible for me to help someone else, in a big way. I would do it all over again, if they asked me.


When I was three, I went through a window and cut myself up badly. In the hospital, as the doctors stitched up my arms, I asked a nurse to hold my hand. And she did.


Firstly, let me say that those who think free health care is not a step forward is not thinking straight. In Australia, it is not entirely free but when I turn up to a public hospital for emergency treatment, I am treated very well and have never been charged. I live in a lower socio-economic area and the local hospital has been outstanding each time I or the children have had an emergency. Very rarely does any of the above happen and when it does it is front page news. Also we are relatively free of jerks here in general medicine. I haven't met an uncaring person in all my times in hospital and I've only heard one or two reports of the odd one. The great majority of staff always read the notes carefully each time they administer anything and doctors seem to be able to be rang at all times of night.

It is not paradise. There are times things go askew and there are often long waiting periods for elective surgeries and questions about what is considered elective so we think it is a shambles. But it is nothing like what you guys have and the immense bills you speak of are appalling. Our family recently baulked at a $900 bill for my father who was treated in a private hospital for 3 weeks in a private room. The only time I was billed for having a baby was when I went to a private hospital and had a c-section - and it was a lot less than $1k. Another c-section, where my son was premature and had to stay in special nursery for several weeks was free because it was a public hospital.

The only area of medicine I can concur with in these comments is that of mental health. I have attempted to get treatment for depression and have found the ratio of jerks goes up dramatically in psychiatry. There is a low cure rate,psychiatric wards are dismal, horrific stories of medication aggravating the problem and patients and their families generally being disrespected or ignored. I often wonder if they think they can get away with it because they can site the patient's mental health in dealing with complaints.


Wish to be anonymous

Most memorable experience: I was 9 and developed excruciating abdominal pain-- couldn't walk, could barely uncurl long enough for them to x-ray me. I was admitted with a preliminary diagnosis of appendicitis and stayed overnight. The x-rays came back negative, the pain eased, and I was discharged the next day with a tentative diagnosis of a bladder infection.

A couple days later it became clear that it had been my first experience with PMS. I don't blame the doctors much for not thinking of that-- I'd *just* turned 9 and it was 1984, when early menarche was a lot less common than it is now.

What works? Due diligence kept me from having unnecessary surgery, even though everyone was sure the x-rays would confirm it was appendicitis. And since I was at a children's hospital, I was interacting with nurses who had been trained to help kids not be overwhelmed and terrified by the experience.

What didn't work? Palliative care. The whole time I was there, no one ever gave me anything for the pain.



Through five deliveries at five different hospitals, what stood out was the extraordinary care given by the labor and delivery nurses. They did whatever it took to help me. They were wonderful, every last one of them.


when I was in the hospital 12 years ago (a respected hospital in boston- a harvard teaching hospital) I had some very annoying problems: (i had just turned 20, btw)

a) my veins (used for iv's) kept inflaming. since I was sick, (and not a doctor), I didn't know to complain. when my dad (a primary care physician) visited, he noticed immediately and started treating me with warm compresses.

b) after my surgery, I was eventually on oral meds- (narcotics) that I had to ask for. so, I asked a nurse around 10 pm- please come to give me my meds when they are due in an hour; I may be asleep but wake me up.

the nurse never came; I woke up at 2 am in a LOT of pain; the nurse claims she came....

c) later, in the emergency room with a 105 degree fever, a student came asking me to answer survey questions. I could barely speak, but I said I would; then I said I would put up one finger for yes, two for no. I may have used the wrong finger...and then she started yelling at me. I had a 105 degree fever! I was glad when she left so I could rest.

I've also had some great nurses- the hospital would give repeat offenders the same nurses- to build a relationship. that helped. luckily, after my surgery I never got admitted again. I had 1 er visit, but no more admittances and am generally fine now.


Paul Hoffman

Most memorable, horrific. Watching my friend die on a ventilator. It was a long story involving literally dozens of friends, but the end was not what it should have been. When the time came to decide whether to intubate or let her die peacefully, the nurse on duty (not one who had worked with her much during her stay) convinced her to go with the ventilator even though everyone (including her doctor) said that there was little hope for recovery.

The result was that she died with a machine in her probably two days longer than if she had gone the way she had wanted to go a few days earlier. And all of us in the room at the time of her death had to deal with the alarm on the ventilator screaming. I don't remember which friend it was (it could have been me), but one of us figured out how to silence it so that my friend could pass with a bit more peace than what had been given to her by this decision.

The system needs to let dying be part of living. It's not like the hospital needed another under-insured person in the ICU for two extra days.



My wife had a bad fall two years ago and broke her foot and several ribs.

Went to the ER, where the doctor felt her foot and claimed to determine that it couldn't be broken, it was supposedly just a sprain. They took X-Rays and we waited for what seemed like an eternity while various persons flitted in and out, pretty much achieving nothing other than taking her blood pressure.

She asked for something for the pain, they wanted to wait for the X-Rays. They disappeared repeatedly, while she was lying there writhing and crying in pain. I went out of the room several times, told whoever I could find that my wife needed something for the pain, now. I was repeatedly promised that they would "check with the doctor".

Finally, after sitting there for a seeming eternity (I'm sure it was at least a half hour, not including her time in the waiting room) with my wife crying in pain, and being promised by about five different people that they would check with the doctor, I snapped.

I went to the desk and bellowed at the top of my lungs that I was going to trash the place if my wife didn't get a pain injection immediately. Suddenly, I got the rapt attention of about four people who'd been blithely ignoring our request for the duration, including a security guard who told me that I was going to be thrown out if I didn't calm down.

It worked though. My wife got a pain injection right away. And sure enough, when the X-Rays came back two hours later, she had a badly broken foot.

I'm absolutely sure that if I'd remained reasonable and simply pleaded for the attention of the staff, she'd of suffered there for several hours with no medication.

It seems that there is a massive reluctance to dispense pain medications in hospitals in general, even to people who really really need it.

I shouldn't have had to go on an obscenity-laden tirade for my wife to get treated like a human being.



I use the Kaiser-Permanente system, the original HMO with a (high but do-able) monthly payment and low co-pays, it's quite different from the whole reimbursement go-round of the health insurance industry. As far as I'm concerned, it's the next best thing to universal single-payer care. I've been through two pregnancies & healthy deliveries, a zillion pediatrician visits (still have the same one, 14 years running), various injuries including two broken legs at the same time. I'm not sure my care was always the highest possible, but I am sure it's never hurt me or my family, and when people made mistakes, they generally fixed them.

They're not perfect, far from, but there's a lot of built-in incentive for them to do preventative care, set up long-term maintenance for chronic conditions like diabetes, and generally treat the whole person, not just the current disease/injury. If everyone in the country had healthcare like this, we'd be a whole lot healthier.



My most memorable experience in a hospital was not during my own visit but a family member's. She had had surgery and a bleeding disorder made itself known after coming home, so she had to return, first to a cardiac ICU then to a step-down unit.

They were monitoring her blood sugar (obsessively and unreasonably, I thought, given that her readings were almost always normal). This was a problem because of her bleeding disorder; being stuck with a lancet several times a day was just not a very good idea. She was also getting a lot of IV medicines. A physician in the family suggested installing a PICC line so she could get her IVs and blood sugar tests without getting stuck all the time.

The problem was that doing anything with a PICC line required an RN only. Aides could not touch them. IV changes weren't a problem because they weren't being changed very often. But checking blood sugar several times a day was a problem, since the RNs were busy. Aides kept coming in and lanceting her fingers even though there was a BIG sign over her bed, next to her monitors, that CLEARLY said "NO FINGER STICKS, PICC LINE ONLY" with her doctor's signature (or whatever that swiggle was!) at the bottom.

More than once I had to stop aides from pricking her fingers, pointing to the sign. One aide just shrugged and tried pricking her other hand! I had a long talk with her RN who said she would take care of it. As long as I was there it never happened again.

That's right. I said, "As long as I was there." Next morning my relative told me she'd been pricked again during the night. I talked to the morning RN who said she'd take care of it. I told her I'd gotten the same assurance from the evening nurse, and it hadn't been enough. I asked what good the sign was if no one was going to obey it. The RN had no good answer. When my relative's doctor showed up I told him that if I heard she was pricked again I'd file a complaint, so he'd best come up with some way to make sure it didn't happen again.

That afternoon they moved her out of the step-down unit to a "regular" room. The staff there were more willing to accept the PICC line and let an RN in to use it, so it was no longer a problem. Nevertheless I made sure the sign was still there. I didn't take chances.

I find it staggering that trained professionals were unable to see a sign -- the size of two sheets of paper, side-by-side, with big block letters over two inches high -- and obey it. How much more simple could it possibly have been? Not to mention, the bleeding disorder in question was not that common, the staff at the hospital were "on notice" about it, no one was under the impression that this was a "normal" problem requiring the usual routine treatment, everyone knew hers was an unusual case because of it.

About a year later the local paper ran a series of articles on this particular hospital, how they'd lost some patients in inexplicable ways, and how the place was being investigated by state authorities. None of these were in any of my relative's wards, but still, it was unnerving ... if people in this place routinely ignored signs, I can see how it might happen.

The fact is that hospitals can be VERY dangerous places. A patient MUST stay on his/her toes, and unfortunately must be extremely distrustful of caregivers ... while "Trust me, I know what I'm doing" might have worked for Sledge Hammer on his eponymous TV series, it doesn't work in medicine. It used to be that you could count on medical professionals to be professional in their conduct, but no longer.