Related Experiment Video
Updated: May 16, 2026
19:57
An Affordable HIV-1 Drug Resistance Monitoring Method for Resource Limited Settings
Published on: March 30, 2014
Using root cause analysis and form redesign to reduce incorrect ordering of HIV tests
Reed A C Siemieniuk1, Kevin Fonseca, M John Gill
1Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada.
Joint Commission Journal on Quality and Patient Safety
|November 24, 2012
Summary
Physicians frequently confused Human T-lymphotropic virus (HTLV-I/II) tests with Human Immunodeficiency Virus (HIV-1/2) tests, leading to diagnostic errors. Requisition redesign significantly reduced these inappropriate HTLV-I/II test orders.
Area of Science:
- Diagnostic Microbiology
- Clinical Pathology
- Virology
Background:
- Advances in molecular biology and microbial nomenclature can introduce diagnostic errors.
- A case highlighted confusion between Human T-lymphotropic virus (HTLV-I/II) testing and Human Immunodeficiency Virus (HIV-1/2) testing.
Purpose of the Study:
- To perform a root cause analysis of erroneous diagnostic testing.
- To identify and address systemic issues leading to inappropriate test ordering.
Main Methods:
- A 17-month period of HTLV-I/II test requests in Southern Alberta was reviewed.
- 555 requests were randomly sampled for appropriateness, and physicians ordering inappropriate tests were surveyed.
Main Results:
- 94% of clinically directed HTLV tests were inappropriate, with only HIV-1/2 testing required.
- Physicians erroneously requested HTLV-I/II tests when HIV-1/2 was indicated.
- Confusing nomenclature, test menus, and form design were identified as root causes.
Conclusions:
- A significant proportion of HTLV-I/II tests were ordered in error due to confusion with HIV-1/2.
- Requisition redesign and careful test menu management can reduce diagnostic errors for physicians.
Related Concept Videos
01:22Healthcare Associated Infections II: Preventive Measures
Essential infection prevention measures are based on the knowledge of the infection chain, the modes of transmission in healthcare settings, and the use of the best practices in all healthcare settings. Compulsory public reporting of healthcare-associated infection rates is needed to allow individuals and the community to make informed choices regarding selecting a healthcare facility.
The best practices for preventing healthcare-associated infections include hand hygiene, patient risk...
The best practices for preventing healthcare-associated infections include hand hygiene, patient risk...
01:24Automated Microbial Diagnostics
Automated diagnostic analyzers have transformed clinical microbiology by providing rapid and reliable methods for pathogen identification and antibiotic susceptibility testing. Among these systems, the Vitek 2 is widely used because it automates the traditionally labor-intensive processes of microbial identification (ID) and antibiotic susceptibility testing (AST), delivering standardized and timely results that are essential for effective patient care.Microbial Identification with ID CardsThe...
01:25Strategies for Assessing and Addressing Confounding
Confounding is a critical issue in epidemiological studies, often leading to misleading conclusions about associations between exposures and outcomes. It occurs when the relationship between the exposure and the outcome is mixed with the effects of other factors that influence the outcome. Given that, addressing confounding is of high importance for drawing accurate inferences in research.
Confounding can be addressed at both the design phase of a study and through analytical methods after data...
Confounding can be addressed at both the design phase of a study and through analytical methods after data...
01:10Documentation of Nursing Diagnosis
The nurse documents nursing diagnoses and enters them into the patient record. The identified patient's nursing diagnosis is either written out with a plan of care or entered into the electronic health record.
In some settings, data-driven computerized decision support systems are in place, allowing for more accurate nursing diagnoses. The database within one of these systems includes diagnostic labels defining characteristics, activities, and indicators for nursing. A nurse enters assessment...
In some settings, data-driven computerized decision support systems are in place, allowing for more accurate nursing diagnoses. The database within one of these systems includes diagnostic labels defining characteristics, activities, and indicators for nursing. A nurse enters assessment...
01:30Health Information Technology and Healthcare Information System
Health Information Technology (HIT)
Health Information Technology, commonly called HIT, integrates advanced information systems and technology in healthcare settings. Its primary functions include:
Health Information Technology, commonly called HIT, integrates advanced information systems and technology in healthcare settings. Its primary functions include:
01:25Errors occurring during blood pressure monitoring
Blood pressure monitoring is a crucial clinical procedure in diagnosing and managing various cardiovascular conditions. Despite its significance, the accuracy of blood pressure measurements can be compromised by multiple factors, potentially leading to either falsely high or low readings. These inaccuracies are critical as they can significantly impact patient care. So, it is vital to understand these challenges deeply and adopt strategic approaches to minimize errors.
Several factors...
Several factors...