Occupational exposure to HIV: response to a system failure

To the Editor: Root-cause analysis is an established, retrospective, structured investigative technique1 that was first introduced into wide clinical practice in public hospitals in Victoria in 2001.2 It is usually reserved for investigating infrequent and significant adverse events and explores the nature and causes of organisational systems failures.1 It is important for all healthcare professionals to understand this technique, as it is used increasingly by healthcare organisations.

Cooper and Blamey’s Lesson from Practice described the outcome of an investigation using root-cause analysis of an occupational exposure to HIV from a needlestick injury.3 We commend the analyses that identified multiple failures of the system for reporting and responding to occupational exposures to hazardous material. The practice changes that ensued at Southern Health demonstrate the value of root-cause analysis.

However, more information and analysis is required about the mistaken use of the stored serum samples. As the authors explain, the initial information was that the source patient tested negative for HIV antibodies. Some time later, it was discovered that the specimen tested was not from the source patient but from a patient of the same surname in the same ward. This caused a 3-day delay between the initial test and the Infectious Diseases Unit being notified that the source patient had twice tested positive for HIV antibodies.

We contend this is an important and common systems failure that usually makes headlines of the form “Wrong site, wrong procedure, wrong person surgery”. The Joint Commission on Accreditation of Healthcare Organisations developed a universal protocol with the intention of highlighting the causative systems failures and minimising the frequency of recurrences of wrong-site surgery.4

The information given by Cooper and Blamey does not clearly explain why (ie, the root cause) the incorrect specimen was tested initially. The pathology department’s review identified the presence of unacceptable “informal norms” in the practice of blood collection and labelling. The suggested remedy that “all serum should be collected with strict adherence to blood collection and labelling protocols” is unlikely to prevent a recurrence. Exhortation to do better rarely solves the underlying problem. It is therefore important to understand why health professionals violate procedures and protocols.5

The experiences of Cooper and Blamey demonstrate that some of the limitations and benefits of root-cause analysis depend on the depth of the investigation. The early and unquestioning acceptance that strict adherence to an existing protocol will prevent another “wrong person” error is not convincing. This contrasts with the well-conducted inquiry and subsequent management of occupational exposure to needlestick injuries.