title: Using root cause analysis and form redesign to reduce incorrect ordering of HIV tests.
abstract: 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.
authors.affiliation: Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada.
authors.forename: Reed A C
authors.initials: RA
authors.lastname: Siemieniuk
authors.forename: Kevin
authors.initials: K
authors.lastname: Fonseca
authors.forename: M John
authors.initials: MJ
authors.lastname: Gill
mesh_terms: D015492:AIDS Serodiagnosis / Q000379:methods / Q000592:standards*; D000416:Alberta; D002984:Clinical Laboratory Information Systems / Q000458:organization & administration / Q000592:standards; D003951:Diagnostic Errors / Q000517:prevention & control* / Q000706:statistics & numerical data; D015658:HIV Infections / Q000175:diagnosis* / Q000821:virology; D015497:HIV-1 / Q000302:isolation & purification; D015498:HIV-2 / Q000302:isolation & purification; D015368:Human T-lymphotropic virus 1 / Q000302:isolation & purification; D015367:Human T-lymphotropic virus 2 / Q000302:isolation & purification; D006801:Humans; D012190:Retroviridae / Q000145:classification; D060891:Root Cause Analysis; D009626:Terminology as Topic