Serratia liquefaciens Infections at a Hemodialysis Center
To the Editor: Dr. Grohskopf and her colleagues (May 17 issue) 1 and the editorialist who commented on their study of Serratia liquefaciens infections at a hemodialysis center 2 missed an opportunity to evaluate the errors in the system that contributed to this “near miss.” The Institute of Medicine...
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| Veröffentlicht in: | The New England journal of medicine 2001-09, Vol.345 (12), p.921-923 |
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| container_issue | 12 |
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| container_title | The New England journal of medicine |
| container_volume | 345 |
| creator | DeOreo, P B Kliger, A S |
| description | To the Editor:
Dr. Grohskopf and her colleagues (May 17 issue)
1
and the editorialist who commented on their study of
Serratia liquefaciens
infections at a hemodialysis center
2
missed an opportunity to evaluate the errors in the system that contributed to this “near miss.” The Institute of Medicine report
3
on the epidemiology of error in medicine shows us the importance of looking for root causes. The authors and editorialist enumerate the human errors or proximate causes that led to the adverse event. There are also remote causes or latent errors that are beyond the control of the health care workers. Training . . . |
| doi_str_mv | 10.1056/NEJM200109203451212 |
| format | Article |
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Dr. Grohskopf and her colleagues (May 17 issue)
1
and the editorialist who commented on their study of
Serratia liquefaciens
infections at a hemodialysis center
2
missed an opportunity to evaluate the errors in the system that contributed to this “near miss.” The Institute of Medicine report
3
on the epidemiology of error in medicine shows us the importance of looking for root causes. The authors and editorialist enumerate the human errors or proximate causes that led to the adverse event. There are also remote causes or latent errors that are beyond the control of the health care workers. Training . . .</description><identifier>ISSN: 0028-4793</identifier><identifier>EISSN: 1533-4406</identifier><identifier>DOI: 10.1056/NEJM200109203451212</identifier><identifier>PMID: 11565529</identifier><language>eng</language><publisher>United States: Massachusetts Medical Society</publisher><subject>Cross Infection - prevention & control ; Disease Outbreaks - prevention & control ; Drug Contamination - economics ; Drug Contamination - prevention & control ; Epoetin Alfa ; Erythropoietin ; Humans ; Medicare ; Recombinant Proteins ; Renal Dialysis - economics ; Serratia Infections - etiology ; United States</subject><ispartof>The New England journal of medicine, 2001-09, Vol.345 (12), p.921-923</ispartof><rights>Copyright © 2001 Massachusetts Medical Society. All rights reserved.</rights><lds50>peer_reviewed</lds50><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-c536t-68af4e25bfe3c018cd6516e4ec4204c5743e332e815733433cd29577190c1e713</citedby><cites>FETCH-LOGICAL-c536t-68af4e25bfe3c018cd6516e4ec4204c5743e332e815733433cd29577190c1e713</cites></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><linktopdf>$$Uhttps://www.nejm.org/doi/pdf/10.1056/NEJM200109203451212$$EPDF$$P50$$Gmms$$H</linktopdf><linktohtml>$$Uhttps://www.nejm.org/doi/full/10.1056/NEJM200109203451212$$EHTML$$P50$$Gmms$$H</linktohtml><link.rule.ids>314,776,780,2746,2747,26080,27901,27902,52357,54039</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/11565529$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>DeOreo, P B</creatorcontrib><creatorcontrib>Kliger, A S</creatorcontrib><title>Serratia liquefaciens Infections at a Hemodialysis Center</title><title>The New England journal of medicine</title><addtitle>N Engl J Med</addtitle><description>To the Editor:
Dr. Grohskopf and her colleagues (May 17 issue)
1
and the editorialist who commented on their study of
Serratia liquefaciens
infections at a hemodialysis center
2
missed an opportunity to evaluate the errors in the system that contributed to this “near miss.” The Institute of Medicine report
3
on the epidemiology of error in medicine shows us the importance of looking for root causes. The authors and editorialist enumerate the human errors or proximate causes that led to the adverse event. There are also remote causes or latent errors that are beyond the control of the health care workers. Training . . .</description><subject>Cross Infection - prevention & control</subject><subject>Disease Outbreaks - prevention & control</subject><subject>Drug Contamination - economics</subject><subject>Drug Contamination - prevention & control</subject><subject>Epoetin Alfa</subject><subject>Erythropoietin</subject><subject>Humans</subject><subject>Medicare</subject><subject>Recombinant Proteins</subject><subject>Renal Dialysis - economics</subject><subject>Serratia Infections - etiology</subject><subject>United States</subject><issn>0028-4793</issn><issn>1533-4406</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2001</creationdate><recordtype>article</recordtype><sourceid>EIF</sourceid><recordid>eNqNkc1Lw0AQxRdRbK3-BYLk5EWiM_uV7FFK1UrVg3oO280EtuSj7qaH_vdGWvAi0rnMHH7vMbzH2CXCLYLSd6-z5xcOgGA4CKmQIz9iY1RCpFKCPmZjAJ6nMjNixM5iXMEwKM0pGyEqrRQ3Y2beKQTbe5vU_mtDlXWe2pjM24pc77vhtH1ikydqutLbeht9TKbU9hTO2Ull60gX-z1hnw-zj-lTunh7nE_vF6lTQvepzm0liatlRcIB5q7UCjVJcpKDdCqTgoTglKPKhJBCuJIblWVowCFlKCbseue7Dt3wYeyLxkdHdW1b6jaxyBBzCTkcAirNc30YiEYcAsoh_HwAxQ50oYsxUFWsg29s2BYIxU9ZxR9lDaqrvf1m2VD5q9m3MwA3O6BpYtHSqvnX7hsnXZht</recordid><startdate>20010920</startdate><enddate>20010920</enddate><creator>DeOreo, P B</creator><creator>Kliger, A S</creator><general>Massachusetts Medical Society</general><scope>CGR</scope><scope>CUY</scope><scope>CVF</scope><scope>ECM</scope><scope>EIF</scope><scope>NPM</scope><scope>AAYXX</scope><scope>CITATION</scope><scope>7X8</scope></search><sort><creationdate>20010920</creationdate><title>Serratia liquefaciens Infections at a Hemodialysis Center</title><author>DeOreo, P B ; Kliger, A S</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-c536t-68af4e25bfe3c018cd6516e4ec4204c5743e332e815733433cd29577190c1e713</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2001</creationdate><topic>Cross Infection - prevention & control</topic><topic>Disease Outbreaks - prevention & control</topic><topic>Drug Contamination - economics</topic><topic>Drug Contamination - prevention & control</topic><topic>Epoetin Alfa</topic><topic>Erythropoietin</topic><topic>Humans</topic><topic>Medicare</topic><topic>Recombinant Proteins</topic><topic>Renal Dialysis - economics</topic><topic>Serratia Infections - etiology</topic><topic>United States</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>DeOreo, P B</creatorcontrib><creatorcontrib>Kliger, A S</creatorcontrib><collection>Medline</collection><collection>MEDLINE</collection><collection>MEDLINE (Ovid)</collection><collection>MEDLINE</collection><collection>MEDLINE</collection><collection>PubMed</collection><collection>CrossRef</collection><collection>MEDLINE - Academic</collection><jtitle>The New England journal of medicine</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>DeOreo, P B</au><au>Kliger, A S</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Serratia liquefaciens Infections at a Hemodialysis Center</atitle><jtitle>The New England journal of medicine</jtitle><addtitle>N Engl J Med</addtitle><date>2001-09-20</date><risdate>2001</risdate><volume>345</volume><issue>12</issue><spage>921</spage><epage>923</epage><pages>921-923</pages><issn>0028-4793</issn><eissn>1533-4406</eissn><abstract>To the Editor:
Dr. Grohskopf and her colleagues (May 17 issue)
1
and the editorialist who commented on their study of
Serratia liquefaciens
infections at a hemodialysis center
2
missed an opportunity to evaluate the errors in the system that contributed to this “near miss.” The Institute of Medicine report
3
on the epidemiology of error in medicine shows us the importance of looking for root causes. The authors and editorialist enumerate the human errors or proximate causes that led to the adverse event. There are also remote causes or latent errors that are beyond the control of the health care workers. Training . . .</abstract><cop>United States</cop><pub>Massachusetts Medical Society</pub><pmid>11565529</pmid><doi>10.1056/NEJM200109203451212</doi><tpages>3</tpages></addata></record> |
| fulltext | fulltext |
| identifier | ISSN: 0028-4793 |
| ispartof | The New England journal of medicine, 2001-09, Vol.345 (12), p.921-923 |
| issn | 0028-4793 1533-4406 |
| language | eng |
| recordid | cdi_proquest_miscellaneous_71184080 |
| source | MEDLINE; EZB-FREE-00999 freely available EZB journals; New England Journal of Medicine |
| subjects | Cross Infection - prevention & control Disease Outbreaks - prevention & control Drug Contamination - economics Drug Contamination - prevention & control Epoetin Alfa Erythropoietin Humans Medicare Recombinant Proteins Renal Dialysis - economics Serratia Infections - etiology United States |
| title | Serratia liquefaciens Infections at a Hemodialysis Center |
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