Skip Navigation
March 2014
image of a pen
 Sign up for monthly email newsletter
Perspectives on Safety icon
Perspectives on Safety
Infection Prevention and Patient Safety
INTERVIEW
In Conversation With… Alison Holmes, MD, MPH
Dr. Holmes is Director of Infection Prevention and Control and a professor at Imperial College London. We spoke with her about infection prevention and patient safety.
(.MP3 | 10.9 MB)
PERSPECTIVE
How Does Infection Prevention Fit Into a Safety Program?
by Susan S. Huang, MD, MPH

This piece describes the history around efforts to address preventable health care–associated infections, including federal initiatives and further research avenues to consider.
Cases & Commentaries
SPOTLIGHT CASE
Hospitalized 3 times within 2 months presumably for sepsis, a woman with diabetes on metformin presented to the emergency department with the same set of symptoms as her previous admissions. After reviewing her records, the admitting team determined that the patient's presentation for this and earlier admissions was more consistent with acute lactic acidosis secondary to metformin than sepsis.
Commentary by William Martinez, MD, MS, and Gerald B. Hickson, MD
CME/CEU credit available for this case

A teenager presented to an urgent care clinic with new bumps and white spots near her tongue. Although she was diagnosed with herpetic gingivostomatitis, the after-visit summary incorrectly populated the diagnosis of "thrush" from the triage information, which was not updated with the correct diagnosis. The mistake on the printout caused confusion for the patient's mother and necessitated several follow-up communications to clear up.
Commentary by William Ventres, MD, MA

Following delivery and successful phototherapy for hyperbilirubinemia, an infant developed anemia over the next few weeks. Found to have Rh hemolytic disease, the infant was admitted to the hospital for blood transfusion and close monitoring.
Commentary by Thomas B. Newman, MD, MPH, and M. Jeffrey Maisels, MB, BCh, DSc
AHRQ PSNet logo
News from AHRQ Patient Safety Network
Visit AHRQ PSNet for patient safety news & info
Photograph of doctor using a computer
Earn CME/CEU Credits
Take our our online quizzes and earn CME/CEU credits
Register Now/Learn More