The AHRQ PSNet Collection comprises an extensive selection of resources relevant to the patient safety community. These resources come in a variety of formats, including literature, research, tools, and Web sites. Resources are identified using the National Library of Medicine’s Medline database, various news and content aggregators, and the expertise of the AHRQ PSNet editorial and technical teams.
… the lesson discovered by Pasteur so many years ago. … PatriceSpath, BA, RHIT … Healthcare Quality Specialist Brown-Spath & Associates Forest Grove, Oregon … WilliamMinogue, MD … Executive Director Maryland Patient …
Throughout most of his life, 19th century French chemist Louis Pasteur insisted that germs were the cause of disease, not the body. It wasn't until Pasteur was nearing the end of his life that he came to believe just the opposite. After reaching this conclusion, he declined treatment for potentially curable pneumonia, reportedly saying, "It is the soil, not the seed."(1) In other words, a germ (the seed) causes disease when our bodies (the soil) provide a hospitable environment.
… to Report " (March 2007) Letter To the editors: Dr. Spath did an excellent job of using the error as a … create the needed catalyst for this willingness. … Patrice L. Spath, BA, RHIT … Brown-Spath & Associates … Susan … Allen … Patrice … Paparella … Vaida … Spath … J … Susan Paparella … …
Dr. Spath did an excellent job of using the error as a springboard to explain the importance of an open and sharing environment of error reporting and learning. Although limited details on the error itself were provided, the information that was contained in the case report does give readers an opportunity to more thoroughly review their own systems to discover if an error such as this can happen in their emergency department (ED).
An infant receives an overdose of the wrong antibiotic (cephazolin instead of ceftriaxone). The nurse spoke with the ED physician on duty but was informed that the medications were essentially equivalent and did not report the error.
Joshi MS, Kazandjian VA, Martin P, et al. Jt Comm J Qual Patient Saf. 2005;31:671-677.
The authors describe key initiatives of the Maryland Patient Safety Center, a 2005 Eisenberg award winner, and propose that their approach can be used as a model for patient safety programs in other states.
The author examines the pros and cons of using root cause analysis to drive system safety improvement. She cautions against “stopping short” by only identifying problems but not supporting initiatives to fix them.