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Nurses play a primary role in patient safety through direct care and through the environments in which care is delivered. While clinical responsibilities are well defined, the nurses’ role in promoting a health care environment that prevents health care–associated infections (HAIs) is not always clear.

A recent report from the Centers for Disease Control and Prevention (CDC) revealed that U.S. hospitals saw meaningful declines in several major HAIs in 2024, including Clostridioides difficile (C. diff) infections, catheter-associated urinary tract infections (CAUTIs), central line–associated bloodstream infections (CLABSIs), and methicillin-resistant Staphylococcus aureus (MRSA) bacteremia. Despite the obvious progress, each day, approximately one in 31 hospitalized patients and one in 43 nursing home residents contract at least one HAI in association with their health care. This alarming statistic underscores the need for frontline vigilance by nurses in every clinical setting.

When the Environment Works Against Us

Infection prevention is often framed around what we can see—dirty floors and high-touch surfaces, visibly soiled equipment, and stained linens. Some of the most consequential risks in health care are not visible. One emerging area of concern is the role of health care water systems as reservoirs for pathogens. Surprisingly, it’s not dirty water that’s being scrutinized, but clean water used every day for patient care and infection prevention practices such as hand hygiene.

Sinks are essential to care and infection prevention practices, but they are also a recognized source of contamination. The CDC has recommended water management plans for the control of Legionella for many years. Organisms such as Pseudomonas aeruginosa, Acinetobacter, and other extended spectrum beta lactamase (ESBL)–producing or carbapenem-resistant Enterobacterales can serve as reservoirs in plumbing systems, creating a source of contamination not addressed through routine surface disinfection. Additionally, even when treated with foaming disinfectants designed for the plumbing system, some organisms reemerged within a week. What makes this risk particularly challenging is that it is:

  • intermittent (appears to resolve, then reoccurs)
  • hidden within infrastructure (biofilms in pipes and drains)
  • influenced by design and behavior (sink use, storage practices, water flow)

The Role of the Nurse: Awareness and Action

Nurses are not responsible for managing health care water systems, but they play a critical role in recognizing and mitigating risk at the point of care. The care environment is also a frequent focus of surveyors from The Joint Commission (TJC) and the Centers for Medicare & Medicaid Services (CMS), particularly during observations of medication preparation and clean supply handling.

In designated clean areas, such as medication preparation spaces, the environment should be maintained to minimize contamination risk. This includes keeping the area around sinks clear and, when possible, incorporating barriers or design features that reduce splashing. During surveys, nurses may be observed preparing medications in these spaces where maintaining a clean, dry environment is essential.

Water exposure in “clean” areas presents more than a surface-level concern. Moisture can compromise medication integrity and contribute to mold growth, while also creating conditions that support organisms such as P. aeruginosa and A. baumannii. These pathogens are often multidrug-resistant and associated with serious, difficult-to-treat infections.

Key considerations to keep in mind:

  • Avoid storing clean or sterile supplies within three feet of sinks
  • Do not store items under sinks because of leak and contamination risk
  • Remove any supplies with visible moisture or water damage
  • Be aware of how routine practices (e.g., disposing of fluids in handwashing sinks) may contribute to contamination
  • Question workflows that place clean items near water sources

Equally important is recognizing patterns such as unexplained infections, persistent moisture issues, or recurring contamination with water sources.

A Necessary Shift in Perspective

Attention to water-related risks does not replace foundational practices. Rather, it reinforces their importance. Foundational practices such as hand hygiene, separation of clean and contaminated items, and proper disinfection remain essential. But as infection prevention evolves, so must our awareness of less visible risks.

The progress reflected in national HAI data is encouraging, but it depends on sustained vigilance at the bedside. For nurses, that includes recognizing that even routine elements—like sinks and water sources—can influence patient outcomes.

Missy Travis, RN, MSN, CIC, FAPIC, is the founder of IP&C Consulting, LLC, a consulting business that supports infection preventionists, health care organizations, business owners, and professional sports teams in developing and sustaining effective infection prevention programs.