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An economic–business approach to clinical risk managementThis paper introduces risk factors in the field of healthcare and discusses the clinical risks, identification, risk management methods, and tools as well as the analysis of specific situations. Based on documentary analysis, an ecient and coherent methodological choice of an informative and non-interpretative approach, it relies on “unobtrusive” and “non-reactive” information sources, such that the research results are not influenced by the research process itself. To ensure objective and systematical analysis, our research involved three macro-phases: (a) the first involved a skimming (a superficial examination) of the documents collected; (b) the second reading (a thorough examination) allowed a selection of useful information; (c) the third phase involved classification and evaluation of the collected data. This iterative process combined the elements of content and thematic analysis that categorised the information into di erent categories which were related to the central issues for research purposes. Finally, from the perspective of safety analysis and risk management, we suggest that comprehensive control and operation should be conducted in a holistic way, including patient safety, cost consumption, and organizational responsibility. An organizational strategy that revolves around a constant and gradual risk management process is an important factor in clinical governance which focuses on the safety of patients, operators, and organizations.
The genotoxic potential of mixed nitrosamines in drinking water involves oxidative stress and Nrf2 activationNitrosamine by-products in drinking water are designated as probable human carcinogens by the IARC, but the health effects of simultaneous exposure to multiple nitrosamines in drinking water remain unknown. Genotoxicity assays were used to assess the effects of both individual and mixed nitrosamines in finished drinking water produced by a large water treatment plant in Shanghai, China. Cytotoxicity and genotoxicity were measured at 1, 10-, 100- and 1000-fold actual concentrations by the Ames test, Comet assay, γ-H2AX assay, and the cytokinesisblock micronuclei assay; oxidative stress and the Nrf2 pathway were also assessed. Nitrosamines detected in drinking water included NDMA (36.45 ng/L), NDPA (44.68 ng/L), and NEMA (37.27 ng/L). Treatment with a mixture of the three nitrosamines at 1000-fold actual drinking-water concentration induced a doubling of revertants in Salmonella typhimurium strain TA100, DNA and chromosome damage in HepG2 cells, while 1–1000-fold concentrations of compounds applied singly lacked these effects. Treatment with 100- and 1000-fold concentrations increased ROS, GSH, and MDA and decreased SOD activity. Thus, nitrosamine mixtures showed greater genotoxic potential than that of the individual compounds. N-Acetylcysteine protected against the nitrosamine-induced chromosome damage, and Nrf2 pathway activation suggested that oxidative stress played pivotal roles in the genotoxic property of the nitrosamine mixtures.