First do no more harm …

Purpose – The purpose of this article is to alert those in positions of trust and authority that there is an urgent need for improvement throughout the entire health profession credentialing process to fix defects at every stage, from employer responsibilities all the way up to licensing board responsibilities and government oversight. Design/methodology/approach – This paper takes the form of a narrative review. Findings – The assumption that layers of safeguards prevent dangerously incompetent or impaired practitioners from continuing to practice in American hospitals is, unfortunately, just that – an assumption. While the vast majority of healthcare professionals uphold the standards of their professions, a recent public health vulnerabilities report reveals serious defects throughout those safeguard layers and widespread harm that results from actions of relatively few determined miscreants who manage to evade them. This not only undermines public trust, but underscores ways in which governing boards, hospital executives and directors have found themselves liable for failings of their institution's quality assurance provisions. That vulnerability report is the result of investigation into one healthcare worker whose narcotic thefts and drug tampering resulted in thousands of patients exposed, dozens infected with hepatitis C, across several states and multiple missed opportunities to constrain. Originality/value – Findings of the Maryland state investigation, coupled with other documents, show that long-recognized ethical and legal responsibilities are not being met effectively.