title: Nosocomial tuberculosis exposures at a tertiary care hospital: a root cause analysis.
abstract: BACKGROUND
  Exposure of health care workers (HCWs) to patients with active TB continues to occur despite implementation of TB control policies.
  
  
  METHODS
  We conducted a root-cause analysis of TB exposures at a tertiary care hospital. Clinical and management details of all confirmed cases identified in 2011 were summarized. Cases were independently reviewed by an expert panel that determined the type (ie, delay in initiating, incorrect use of or premature removal of control measures), preventability, and root cause(s) of each error (exposure).
  
  
  RESULTS
  Fifteen cases were reviewed. Ten errors were identified in 7 (47%) cases. Cases associated with errors were older than those without errors (68 y vs 40 y; P = .037). Most cases (12/15) were foreign born. A delay in initiating airborne precautions accounted for 70% (7/10) of the errors. The expert panel determined that 80% (8/10) of the errors were preventable or possibly preventable. The most common root causes were failure to consider TB and failure to obtain and interpret imaging. Advanced age, atypical presentation, and presence of comorbid illnesses were common among the preventable cases.
  
  
  CONCLUSIONS
  TB control policies do not prevent all exposures. Our findings suggest that consideration of TB in elderly patients with risk factors, even if their signs and symptoms can be explained by an alternative diagnosis or are atypical, followed by a review of imaging studies, can further reduce this risk.
authors.affiliation: Department of Medicine, University of Toronto, Toronto, ON, Canada.
authors.forename: Navjeet
authors.initials: N
authors.lastname: Uppal
authors.affiliation: Division of Respirology, Department of Medicine, St Michael's Hospital, Toronto, ON, Canada.
authors.forename: Jane
authors.initials: J
authors.lastname: Batt
authors.affiliation: Division of Respirology, Department of Medicine, St Michael's Hospital, Toronto, ON, Canada.
authors.forename: Julie
authors.initials: J
authors.lastname: Seemangal
authors.affiliation: Corporate Health and Safety Services, St Michael's Hospital, Toronto, ON, Canada.
authors.forename: Susan A
authors.initials: SA
authors.lastname: McIntyre
authors.affiliation: Infection Prevention and Control, St. Michael's Hospital, Toronto, ON, Canada.
authors.forename: Nemat
authors.initials: N
authors.lastname: Aliyev
authors.affiliation: Division of Infectious Diseases, Department of Medicine, St Michael's Hospital, Toronto, ON, Canada. Electronic address: Mullerm@smh.ca.
authors.forename: Matthew P
authors.initials: MP
authors.lastname: Muller
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003428:Cross Infection / Q000453:epidemiology*; D005260:Female; D006801:Humans; D017053:Infection Control / Q000379:methods*; D008297:Male; D008875:Middle Aged; D016273:Occupational Exposure / Q000517:prevention & control*; D060891:Root Cause Analysis; D062606:Tertiary Care Centers; D014376:Tuberculosis / Q000453:epidemiology*; D055815:Young Adult
keywords: Cross-infection; Quality improvement