Stross J K, Shasby M, Harlan W R
N Engl J Med. 1976 Nov 11;295(20):1107-10. doi: 10.1056/NEJM197611112952004.
Over a six-week period, a striking increase in the incidence of cardiopulmonary arrests occurred at the Ann Arbor Veterans Administration Hospital, Criminal administration of a muscle-paralyzing agent was implicated. An epidemiologic investigation les to a description of the classic features of an epidemic; time, place, person, agent and mode of transmission. Control of the agent and susceptible patients led to cessation of the epidemic. Although the perpetrator was not specifically identified, the concurrent criminal investigation was aided by the data developed in the medical investigation. On the basis of this experience, we propose a surveilliance mechanism for early detection of increased critical incidents, such as cardiopulmonary arrests, and a scheme for systematically examining similar events.
在六周的时间里，安阿伯退伍军人管理局医院心肺骤停的发生率显著上升，原因被认为与肌肉麻痹剂的不当使用有关。一项流行病学调查描述了该疫情的典型特征：时间、地点、人物、病原体和传播方式。对病原体和易感患者的控制使得疫情得以终止。尽管肇事者未被明确识别，但刑事调查借助了医学调查中得出的数据。基于这一经验，我们提出了一种监测机制，用于早期发现诸如心肺骤停等危急事件的增加情况，以及一种系统检查类似事件的方案。
