What’s past is prologue: Organizational learning from a serious patient injury

This exploratory case study examines how one hospital learned from an adverse event (AE), a medication overdose that seriously injured a patient. Using qualitative data analysis, we examined how four professional groups reacted to the AE: physicians, nurses, pharmacists, and representatives from the combined quality assurance and risk management departments. Following the AE, each professional group classified the event differently, assessed a different segment of history, made decisions about different issues, and chose different courses of action. Despite these differences, the physician, nursing and pharmacy management teams all decided on which solutions to implement before the first root cause analysis meeting was convened. Indeed, to understand how the hospital implemented changes in the aftermath of the AE, it was necessary to examine the learning from near misses and other warnings that preceded it. This case highlights the importance of the politics of organizational learning and raises theoretical and practical questions about how hospitals learn from potential and actual adverse events.     

Utilization of the solid sorbent media in monitoring of airborne cyclophosphamide concentrations and the implications for occupational hygiene

The main objective of the study was to evaluate the applicability of two solid sorbent media (Anasorb 708 and Strata X), the impinger filled with distilled water and PTFE filters for determination of airborne cyclophosphamide (CP) in the hospital working environment. For this purpose, air contamination of Masaryk Memorial Cancer Institute (Czech Republic) was monitored using the sampling apparatus containing the samplers described above. In addition, the surface contamination was also determined using the wipe sampling technique. During the monitoring, contamination of three different workplaces (storage room, preparation room and outpatient clinic) was studied. Using Strata X solid sorbent tubes, airborne CP was determined in all (n = 5) samples collected at the outpatient clinic over a 5 day monitoring period (concentration range: 0.3-4.3 ng m(-3)). Other samplers (including PTFE filters) did not collect any detectable amount of CP (the limit of detection, LOD ≤ 0.1 ng m(-3)). Negative results detected at filter samples indicate that CP determined at Strata X samples was most probably of gaseous origin. Surface contamination ranged from <2 to 19, <8 to 418 and 133-15,500 pg cm(-2) at the storage room, preparation room and outpatient clinic, respectively. The study showed that evaporation of antineoplastic drugs should not be neglected, albeit the concentrations determined in our study are relatively low. Therefore, proper monitoring of airborne contamination should involve simultaneous sampling of both particle-bonded and gaseous phases. In this way, Strata X sorbent tubes seem to be an effective tool for the sampling of gaseous CP in the indoor air.     

Degradation of antibacterial 1-octylpyrrolidin-2-one by bacterial pairs isolated from river water and soil

Environmental Science and Pollution Research - The study of bacterial degradation of 1-octylpyrrolidin-2-one (NOP) by river water and soil bacteria was the main aim of the research. Although the...     

The toxicity of the glyphosate herbicide for Pardosa spiders’ predatory activity depends on the formulation of the glyphosate product

Environmental Chemistry Letters - Glyphosate is an herbicide which was previously considered safe for non-target organisms. 825.8&nbsp;million kilograms of glyphosate-based products were used...     

Mutagens in raw ewe milk in Orava region,northern Slovakia: metals

Environmental Science and Pollution Research - The aim of this work was to determine the concentrations of selected mutagenic elements (As, Cd, Co, Cr, Cu, Fe, Mn, Ni, Pb, and Se) in raw ewe milk...