| Using root cause analysis and form redesign to reduce incorrect ordering of HIV tests. | |
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MedLine Citation:
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PMID: 23173397 Owner: NLM Status: In-Process |
Abstract/OtherAbstract:
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BACKGROUND: Advances in molecular biology and changes in microbial nomenclature may subject diagnostic microbiology to errors. A patient diagnosed with Pneumocystis jiroveci pneumonia and then with AIDS had received a negative "AIDS test"--"negative for antibodies to HTLV 1 and 2." The test requisition showed that the physician had requested HTLV-I/II testing but not an HIV-1/2 test. A root cause analysis was performed to determine if the erroneous testing represented a systemic problem. A study was conducted to identify and address such testing errors. METHODS: For the 1,952 HTLV-I/II test requests in a 17-month period in the Southern Alberta region, a random representative sample of 555 requests for HTLV-I/II testing were evaluated for appropriateness. Physicians ordering "inappropriate" tests were surveyed to determine root causes, and the HTLV-I/II check box was subsequently removed from the requisition. RESULTS: Some 318 (94%) of the 340 clinically directed HTLV tests were likely or definitely inappropriate--that is, only an HIV-1/2 test was required. At least 81% (127/156) of the 8% (156/1,948) of the HTLV-I/II tests ordered without an HIV-1/2 test concurrently were ordered inappropriately. In the telephone survey, all 69 physicians suspected to have incorrectly ordered HTLV-I/II tests reported erroneously requesting HTLV for HIV. A root cause analysis identified confusing viral nomenclature, diagnostic testing menu, and form design as contributing factors. A requisition recall and redesign has reduced erroneous laboratory testing. CONCLUSIONS: A high proportion of HTLV-I/II tests were ordered erroneously and confused with HIV-1/2. Careful attention to routine test menus and form design, including the exclusion of rare and confusing pathogens, reduces risk of error for practicing physicians. |
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Authors:
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Reed A C Siemieniuk; Kevin Fonseca; M John Gill |
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Publication Detail:
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Type: Journal Article |
Journal Detail:
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Title: Joint Commission journal on quality and patient safety / Joint Commission Resources Volume: 38 ISSN: 1553-7250 ISO Abbreviation: Jt Comm J Qual Patient Saf Publication Date: 2012 Nov |
Date Detail:
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Created Date: 2012-11-22 Completed Date: - Revised Date: - |
Medline Journal Info:
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Nlm Unique ID: 101238023 Medline TA: Jt Comm J Qual Patient Saf Country: United States |
Other Details:
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Languages: eng Pagination: 506-12 Citation Subset: IM |
Affiliation:
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Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada. |
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From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine
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