ourteen newborns died in a fire at the Pakistan Institute of Medical Sciences in Islamabad on August 26. The precise source of the fire is still under investigation but an interim inquiry has already established that in the federal capital’s most advanced tertiary care hospital, fire and life-safety arrangements were inadequate; there was no properly communicated and rehearsed nursery evacuation plan; and an emergency call was recorded about 16 minutes after the fire first became visible on CCTV.

More disturbingly, the PIMS had experienced a fire in its nursing hostel on July 6. Inquiry findings highlighted the same gaps: fire alarms, electrical inspections, evacuation procedures, firefighting equipment and staff training.

The PIMS tragedy exemplifies a problem common to many sectors: tragedies are investigated as one-off events; learning does not translate into institutional memory or change in practices. One has to ask how many more must die before we wake up.

The HIV outbreaks among children tell the same story. The Ratodero disaster in 2019 exposed the problem of unsafe injections, weak infection control, unsafe blood-bank practices and poor waste management. WHO investigators subsequently found blood banks using HIV screening tests that were not WHO-prequalified and lacked adequate quality control.

Years later, Taunsa produced a similar pediatric HIV crisis. At least 331 children tested positive between November 2024 and October 2025. Months after the authorities had announced a crackdown and put in place infection-control measures, undercover reporting documented syringe reuse, contaminated multi-dose vials and other unsafe practices. Another high-level committee was formed, with little apparent resolve to bring about serious change.

Pakistan has the required capacity and facilities.

The Punjab’s healthcare standards, for example, already covers infection control, facility safety, continuous quality improvement, management responsibility and patient complaints. Blood safety standards also require quality-assured screening for HIV and other transfusion-transmissible infections. The failure is between an SOP or standard being written and the required diligent compliance with verification by the implementing party (hospital, providers or clinic facilities and government regulatory oversight). Corruption and collusion undermine the system on a daily basis.

Our response to failure also remains excessively personalised.

A tragedy is followed by suspensions, transfers, committees and demands that “heads roll.” Individual negligence should be investigated. But punishment alone cannot ensure that recommendations to prevent fires or unsafe injection practices are thoroughly implemented. A systemic approach asks questions: what failed? Who owns the correction? By when must it be fixed? Who verifies closure?

Changing behaviours

First, every serious preventable event—hospital or building fire, transfusion-related, healthcare-associated HIV or hepatitis infection, major medication error—should be treated as a sentinel event. A root-cause review should generate a short corrective-action register: action, responsible officer, deadline, verification status. The case remains open until every high-risk action has been independently verified, not merely reported as completed. Every similar facility should be inspected at random for rapid verification checks (lot quality sampling technique).

Second, lessons must travel beyond the hospital(s) where the tragedy occurred. A PIMS fire should automatically trigger a time-bound fire and evacuation audit of neonatal units, ICUs and operation theatres in comparable hospitals. An unsafe-injection outbreak should trigger injection-safety and blood-bank audits across the affected district and province. One institution’s catastrophe should become every institution’s warning.

Third, regulators must shift from episodic inspection toward continuous (technology-guided) assurance. Bangladesh has used monthly infection-prevention scorecards to identify facility gaps and target corrective action. India’s quality-assurance system uses structured assessment of public health facilities. Pakistan can learn the discipline of repeated measurement, corrective action and verification (with a stern eye for collusion and corruption practices).

Finally, patients need standing, not sympathy. Hospitals should be required to publish quarterly safety dashboards, major adverse events, infection-control compliance, blood-screening quality assurance, fire drills, complaints and corrective actions closed and include patient or community representatives in quality reviews. Hospital standards in the Punjab already require complaints to feed into quality improvement. The principle needs to become a routine governance tool.

The WHO patient-safety framework makes the same point: incident reporting should generate structured learning, risk reduction and feedback. Information that produces no management action is merely documentation of failure.

Shocked, the people are waiting to see if the PIMS tragedy will break this sad cycle. Whether six months from now, every hospital in the federal capital and beyond can have a functioning alarm, a rehearsed evacuation plan, tested electrical systems and documented corrective actions—and whether we, the citizens, can see the evidence.

When institutions, whether public or private, repeatedly rediscover the same failure after lives have been lost, the problem is no longer lack of knowledge—it is lack of accountability to learn and indifference to change.

The writer is the CEO of the Akhter Hameed Khan Foundation (www.ahk-foundation.org), an Islamabad based community organisation working on women’s primary and reproductive health and economic empowerment.