Repeated outbreaks of Clostridium difficile (C diff) spread through Stoke Mandeville hospital in Aylesbury, Bucks, between October 2003 and June 2005.
Some 334 patients were infected during their stay and at least 33 died.
The Health and Safety Executive report follows a Healthcare Commission investigation which found "serious and significant" failings in the way senior hospital managers responded to the outbreaks.
Lessons were not learned from one outbreak of C diff between October 2003 and June 2004 and senior managers failed to bring a second outbreak in 2005 quickly under control, the commission found.
Instead, their focus was on other things, the report said, such as meeting Government targets on accident and emergency waiting times.
The study detailed how patients with diarrhoea were kept in or put on open wards rather than in isolation rooms.
A shortage of nurses "probably contributed to the spread of infection" because staff were "too rushed to take basic precautions such as washing their hands, wearing aprons and gloves consistently, emptying commodes promptly and cleaning mattresses and equipment properly," it said.
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