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MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; August 13, 2007.
This announcement describes a fatal overdose of a protease inhibitor in an infant and discusses how to prevent such occurrences.
Harrisburg, PA: Patient Safety Authority; May 2019.
This report summarizes patient safety improvement work in the state of Pennsylvania and reviews the 2018 activities of the Patient Safety Authority, including the launch of the Center of Excellence for Improving Diagnosis, outreach programs, liaison efforts, and the convening of the first patient safety conference for the state.
Journal Article > Study
Readmission after delayed diagnosis of surgical site infection: a focus on prevention using the American College of Surgeons National Surgical Quality Improvement Program.
Gibson A, Tevis S, Kennedy G. Am J Surg. 2014;207:832-839.
The National Surgical Quality Improvement Program (NSQIP) was developed to monitor and enhance the quality of surgical care. This retrospective study used the NSQIP indicators to identify cases of surgical site infections. Researchers found that nearly 50% of patients were diagnosed following hospital discharge, and many of these infections led to readmissions. Patients who presented with a surgical site infection after discharge were less likely to smoke or have chronic cardiopulmonary illness. The authors suggest that closer postdischarge follow-up might have prevented some readmissions they identified. However, prior studies did not show a benefit to early follow-up. A past AHRQ WebM&M commentary discussed environmental safety in the operating room and its relationship to surgical site infections.
Journal Article > Commentary
Liu J, Kaye KS, Mercuro NJ, et al. Infect Control Hosp Epidemiol. 2019;40:206-207.
Never events are devastating to patients and indicate serious underlying organizational safety problems. This commentary suggests that there are types of inappropriate antibiotic use behaviors that should be categorized as never events, such as use of an antibiotic longer than is required. The authors believe that labeling these incidents as never events will drive development and application of prevention strategies.