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.
Key Words
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Article info
Publication history
Published online: March 24, 2014
Footnotes
Conflict of interest: None to report.
Identification
Copyright
© 2014 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
