ABSTRACT
BACKGROUND: Proper patient identification is a major factor affecting patient safety in any health care organization. METHODS: An interdisciplinary team, using three Plan-Do-Study-Act (PDSA) cycles, reviewed the incidence of patient misidentifications resulting from registration process errors. Retrospective and prospective data were collected to determine the incidence among inpatients and outpatients. RESULTS: Registration-associated patient misidentification errors occurred 7 to 15 times per month. Information systems deficiencies, inadequate training, and the lack of a single master patient index were among the root causes identified. After three PDSA cycles, the incidence rate for registration-associated patient misidentification errors declined for inpatients (80.5%) but increased for outpatients (30.2%). DISCUSSION: Through an iterative process as implied in the PDSA cycle, registration-associated patient misidentification errors for established Johns Hopkins Hospital patients were dramatically reduced. A checklist is provided for other organizations to assess their vulnerability to registration-associated patient misidentification errors. The checklist suggests, for example, that organizations strive to develop a single master patient index and limit access to registration systems to staff with proper training and performance expectations.
Subject(s)
Patient Identification Systems/organization & administration , Process Assessment, Health Care/organization & administration , Quality Assurance, Health Care/organization & administration , Academic Medical Centers , Humans , Interdisciplinary Communication , Medical Errors/prevention & control , Prospective StudiesABSTRACT
PURPOSE: To provide a summary of the outcomes of two working conferences organized by the Centers for Disease Control and Prevention (CDC), to develop recommendations for practical, sustainable mechanisms to make quality control (QC) materials available to the genetic testing community. METHODS: Participants were selected to include experts in genetic testing and molecular diagnostics from professional organizations, government agencies, industry, laboratories, academic institutions, cell repositories, and proficiency testing (PT)/external Quality Assessment (EQA) programs. Current efforts to develop QC materials for genetic tests were reviewed; key issues and areas of need were identified; and workgroups were formed to address each area of need and to formulate recommendations and next steps. RESULTS: Recommendations were developed toward establishing a sustainable process to improve the availability of appropriate QC materials for genetic testing, with an emphasis on molecular genetic testing as an initial step. CONCLUSIONS: Improving the availability of appropriate QC materials is of critical importance for assuring the quality of genetic testing, enhancing performance evaluation and PT/EQA programs, and facilitating new test development. To meet the needs of the rapidly expanding capacity of genetic testing in clinical and public health settings, a comprehensive, coordinated program should be developed. A Genetic Testing Quality Control Materials Program has therefore been established by CDC in March 2005 to serve these needs.
Subject(s)
Genetic Testing/standards , Molecular Diagnostic Techniques/standards , Quality Control , Centers for Disease Control and Prevention, U.S. , Government Regulation , Humans , Quality Assurance, Health Care/standards , Reproducibility of Results , United StatesABSTRACT
A atividade metabólica do M. tuberculosis sob diversas condiçöes experimentais foi estudada utilizando um sistema radiométrico automático, capaz de quantificar o 14CO2 produzido pela oxidaçäo de substâncias marcadas com Carbono-14. As experiências realizadas incluíram: a) vias metabólicas; b) determinaçäo dos tempos de detecçäo para inoculaçöes de diversas magnitudes; c) efeito da filtraçäo sobre a reprodutibilidade dos resultados; d) influência de meio hostil; e) determinaçäo das concentraçöes inibitórias mínimas para hidrazida, estreptomicina, etambutol e rifampicina; f) tempo de duplicaçäo para o M. tuberculosis e M. bovis. Estes microorganismos metabolizaram até 14CO2 o 14C-formato, (U-14C) acetato, (u-14C) glicerol, (1-14C) ácido palmítico, (1-14C) ácido láurico, (u-14C) L-ácido málico, (U-14C) D-glicose e (1-14C) D-glicose, mas näo (1-14C) L-glicose, (u-14C) glicina ou (U-14C) piruvato. Usando 14C-formato, (1-14C) ácido palmítico ou (1-14C) ácido láurico foi possível detectar 10 bacilos/frasco em 24-48 horas e até 10 bacilos/frasco em 16-20 dias. Resultados reprodutíveis foram obtidos sem filtrar a suspensäo de bactérias, desde que cultivadas em meio 7H9 líquido com 0,05% de polissorbato 80 e homogenizadas antes da experiência. Drogas que bloqueiam a síntese protêica apresentaram concentraçäo inibitória mínima menor com o método radiométrico do que com o convencional. O tempo médio de duplicaçäo para o M. bovis e várias cepas de M. tuberculosis com diversas substâncias marcadas foi 9 + ou - 1 horas
