Propionibacterium acnes delayed infection following spinal surgery with instrumentation.

Related Articles Propionibacterium acnes delayed infection following spinal surgery with instrumentation. Musculoskelet Surg. 2012 Mar 23; Authors: Mhaidli HH, Der-Boghossian AH, Haidar RK Abstract Propionibacterium acnes detection in culture media was previously considered a contamination but recently its infectious role was discovered in post-spinal surgery infections. P. acnes might be introduced during surgery. Its diagnosis…

Medical error: a 60-year-old man with delayed care for a renal mass.

Medical error: a 60-year-old man with delayed care for a renal mass.

JAMA. 2011 May 11;305(18):1890-8

Authors: Schiff GD

Mr B, a 60-year-old man with back pain, was not informed of an incidental finding of a renal mass suggestive of cancer on a magnetic resonance imaging scan. Failure and delays in test follow-up are a frequent problem in medicine, occurring in more than 5% of significantly abnormal ambulatory test results. Rather than simply blaming involved clinicians, systems for managing tests need to be reengineered using methods from reliability sciences. These begin with investigations into the systemic causes of the failures, then application of approaches such as heightened situational awareness, closed-loop systems, improved handoffs, just-in-time work, culture and practices of stopping to fix problems, forcing functions and simplification, enhanced visual cues, and cautious use of information technology and redundancy, all while avoiding suboptimization. Emerging test management systems and critical test follow-up recommendations illustrate how applying these principles can enhance this important aspect of patient safety.

PMID: 21486963 [PubMed – indexed for MEDLINE]