title: Capnocytophaga canimorsus meningitis after routine myelography: a sentinel event identifies multiple opportunities for improvement of standard practices in radiology.
abstract: Meningitis developed after a routine myelogram in a healthy patient. When Capnocytophaga canimorsus was identified, investigations revealed that the patient, the radiologist, and the staff were all dog owners. Multiple deviations from recommended practices in radiology were identified and corrected. The investigation of an unusual sentinel event allowed multiple interventions to be implemented simultaneously, with resultant risk reduction for subsequent radiologic procedures.
authors.affiliation: PC, Missoula, MT 59802, USA. risi@saintpatrick.org
authors.forename: George Franklin
authors.initials: GF
authors.lastname: Risi
authors.forename: Chad Alan
authors.initials: CA
authors.lastname: Spangler
mesh_terms: D000368:Aged; D002206:Capnocytophaga / Q000187:drug effects* / Q000302:isolation & purification*; D005260:Female; D016905:Gram-Negative Bacterial Infections / Q000382:microbiology*; D006801:Humans; D017053:Infection Control / Q000379:methods; D016920:Meningitis, Bacterial / Q000382:microbiology*; D009192:Myelography