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Staggered Sensitivity Results
Guglielmo BJ. AHRQ WebM&M [serial online]. March 2007.
Several days after a patient’s surgery, preliminary wound cultures grew
Staphylococcus aureus
. Although the final sensitivity profile for the cultures showed resistance to the antibiotic that the patient was receiving, the care team was not notified and the patient died of sepsis.
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Commentary
Setting of Care
Hospitals
Target Audience
Health Care Providers
Health Care Executives and Administrators
Clinical Area
Surgery
Infectious Diseases
Safety Target
Medication Errors/Preventable Adverse Drug Events
Nosocomial Infections
Missed or Critical Lab Results
Surgical Site Infections
Error Types
Active Errors
Latent Errors
Approach to Improving Safety
Quality Improvement Strategies
Communication between Providers
Laboratory Result Tracking Improvement
Computerized Decision Support