An independent inquiry is to be held at a hospital where eight patients died from the bug Clostridium difficile, the Scottish Government has announced.
Health Secretary Nicola Sturgeon said she was "deeply concerned" more than 50 cases at Vale of Leven Hospital only came to light retrospectively.
She said the NHS board running the Dunbartonshire hospital was already taking action.
Ms Sturgeon told MSPs the issue raised serious cause for concern.
She also said staff had expressed concerns for years.
The retrospective investigation by NHS Greater Glasgow and Clyde found 54 cases of C.diff between December 2007 and June this year at the hospital, in Alexandria.
Eight patients died as a direct result and the infection was a contributory factor in a further nine deaths.
Health Secretary Nicola Sturgeon interviewed on Newsnight Scotland
Speaking in Holyrood, Ms Sturgeon said infection control experts found a lack of hand hygiene basins at the Vale of Leven's toilets and that many commodes were not fit for use.
Gloves and aprons were not readily available and bed spacing fell short of health and safety recommendations, she added.
"The reports that I have recovered from NHS Greater Glasgow and Clyde raise serious cause for concern," said Ms Sturgeon, who told parliament the case for an independent inquiry was overwhelming.
"They suggest that the surveillance systems in place at the hospital were inadequate and did not alert the board to the number and pattern of cases."
The review, to be led by Professor Cairns Smith, the professor of public health at Aberdeen University, will examine the circumstances surrounding all the C.diff cases and will make recommendations by the end of July.
But Ms Sturgeon said lessons learned would be used to drive down C.diff rates across Scotland and all infection control managers had been asked to review their data on C.diff over the past six months.
NHS Greater Glasgow and Clyde, the health secretary added, had embarked on a "concerted drive" towards improving hand hygiene and an urgent review of the use of antibiotics - known to reduce the body's natural defences to C.diff.
The health board has also agreed to upgrade facilities at the Vale of Leven.
Labour health spokeswoman Margaret Curran pressed Ms Sturgeon over claims she had not revealed the full extent of the problem at an earlier date - but the heath secretary said she had been "persistently clear".
Her comments came after it was understood Ms Sturgeon was officially informed of the deaths last Tuesday.
However, the BBC learned she was told by a local newspaper four days earlier that at least five people had died.
Ms Sturgeon offered her condolences but waited for official confirmation before taking further action.
Tory health spokeswoman Mary Scanlon said the "outbreaks" raised concerns over how hospitals were prioritising infection control.
And Ms Sturgeon agreed with Liberal Democrat Ross Finnie that the health board's response to the problem as "very unhelpful".
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