The FilmArray respiratory virus panel detects 15 viral agents in respiratory specimens using polymerase chain reaction. We performed FilmArray respiratory viral testing in a core laboratory at a regional children's hospital that provides service 24 hours a day 7 days a week. The average and median turnaround time were 1.6 and 1.4 hours, respectively, in contrast to 7 and 6.5 hours documented 1 year previously at an on-site reference laboratory using a direct fluorescence assay (DFA) that detected 8 viral agents. During the study period, rhinovirus was detected in 20% and coronavirus in 6% of samples using FilmArray; these viruses would not have been detected with DFA. We followed 97 patients with influenza A or influenza B who received care at the emergency department (ED). Overall, 79 patients (81%) were given oseltamivir in a timely manner defined as receiving the drug in the ED, a prescription in the ED, or a prescription within 3 hours of ED discharge. Our results demonstrate that molecular technology can be successfully deployed in a nonspecialty, high-volume, multidisciplinary core laboratory.

Quality indicators (QIs) are fundamental tools for enabling users to quantify the quality of all operational processes by comparing it against a defined criterion. QIs data should be collected over time to identify, correct, and continuously monitor defects and improve performance and patient safety by identifying and implementing effective interventions. According to the international standard for medical laboratories accreditation, the laboratory shall establish and periodically review QIs to monitor and evaluate performance throughout critical aspects of pre-, intra-, and post-analytical processes. However, while some interesting programs on indicators in the total testing process have been developed in some countries, there is no consensus for the production of joint recommendations focusing on the adoption of universal QIs and common terminology in the total testing process. A preliminary agreement has been achieved in a Consensus Conference organized in Padua in 2013, after revising the model of quality indicators (MQI) developed by the Working Group on "Laboratory Errors and Patient Safety" of the International Federation of Clinical Chemistry and Laboratory Medicine (IFCC). The consensually accepted list of QIs, which takes into consideration both their importance and applicability, should be tested by all potentially interested clinical laboratories to identify further steps in the harmonization project.

We developed a laboratory incident report classification system that can guide reduction of actual and potential adverse events. The system was applied retrospectively to 129 incident reports occurring during a 16-month period. Incidents were classified by type of adverse event (actual or potential), specific and potential patient impact, nature of laboratory involvement, testing phase, and preventability. Of 129 incidents, 95% were potential adverse events. The most common specific impact was delay in receiving test results (85%). The average potential impact was 2.9 (SD, 1.0; median, 3; scale, 1-5). The laboratory alone was responsible for 60% of the incidents; 21% were due solely to problems outside the laboratory's authority. The laboratory function most frequently implicated in incidents was specimen processing (31%). The preanalytic testing phase was involved in 71% of incidents, the analytic in 18%, and the postanalytic in 11%. The most common preanalytic problem was specimen transportation (16%). The average preventability score was 4.0 (range, 1-5; median, 4; scale, 1-5), and 94 incidents (73%) were preventable (score, 3 or more). Of the 94 preventable incidents, 30% involved cognitive errors, defined as incorrect choices caused by insufficient knowledge, and 73% involved noncognitive errors, defined as inadvertent or unconscious lapses in expected automatic behavior.

The functions of glial cells in the nervous system are not well defined, with the exception of myelin production by oligodendrocytes, uptake of amino-acid synaptic transmitters, and a contribution to extracellular potassium homeostasis. Neuroglia have receptors for neurotransmitters which may be involved in neuron-glia interactions. Recent studies have demonstrated voltage-gated ion channels in glial membranes. In a study of the optic nerve of the frog, small areas of the surface were examined with the loose patch-clamp method, and voltage-gated Na+ and K+ channels, presumably located in the membranes of the astrocytes forming the glia limitans, were identified. We now report that nerve impulses in the axons of the frog optic nerve transiently alter the properties of the voltage-dependent membrane channels of the surface glial cells (astrocytes), a demonstration of a new form of neuron-glia interaction.

Membrane potential recording from glial cells in Necturus optic nerve in the presence of 2 mM Ba++, which was added to block the K+ conductance, gave the following results. 1) In HCO3- -free, low-Na+ solutions (11% of control; Na+ replaced with N-methyl-D-glucamine), the hyperpolarizing effect of adding 10 mM HCO3- was reduced by approximately 80%. 2) 4-acetamido-4'-isothiocyanato-stilbene-2,2'-disulfonic acid (SITS, 0.1 or 1 mM) reduced the effect of HCO3- by at least 50%. 3) In the presence of HCO3-, reduction of Na+ caused a depolarization which was much larger than that observed in nominally HCO3- -free solutions. These observations indicate the presence in the glial membrane of an electrogenic Na+/HCO3- cotransporter in which the stoichiometry of HCO3- to Na+ is greater than 1.

We developed a strategy to determine the clinical impact associated with errors in clinical microbiology testing. Over a 9-month period, we used a sequential three-stage method to prospectively evaluate 480 consecutive corrected microbiology laboratory reports. The three stages were physician review of the corrected report, medical record review, and interview with the clinician(s) taking care of the patient. Of the 480 corrected reports, 301 (62.7%) were ruled out for significant clinical impact by physician review and an additional 25 cases (5.2%) were ruled out for clinical impact by medical record review. This left 154 cases (32.1%) that required clinician interview to determine clinical impact. The clinician interview revealed that 32 (6.7%) of the corrected reports were associated with adverse clinical impact. Of these 32 cases, 19 (59.4%) involved delayed therapy, 8 (25.0%) involved unnecessary therapy, 8 (25.0%) were associated with inappropriate therapy, and 4 (12.5%) were associated with an increased level of care. The laboratory was entirely responsible for the error in 28 (87.5%) of the 32 cases and partially responsible in the other 4 cases (12.5%). Twenty-six (81.3%) of the 32 cases involved potentially preventable analytic errors that were due to lack of knowledge (cognitive error). In summary, we used evaluation of corrected reports to identify laboratory errors with adverse clinical impact, and most of the errors were amenable to laboratory-based interventions. Our method has the potential to be implemented in other laboratory settings to identify and characterize errors that impact patient safety.In 2000, the Institute of Medicine published the report, To Err is Human (5), which stated that adverse events are not uncommon and result in an estimated 44,000 to 98,000 hospital deaths per year. This publication has generated widespread interest in strategies for detecting and reducing adverse events related to medical errors. There are a number of published studies on clinical laboratory errors, and these focus primarily on the rate of laboratory errors and the classification of the errors (for a review, see reference 2). However, there is little data on laboratory-related adverse events, defined as physical insults or injuries due to laboratory error and not due to the patient's underlying condition.There are two obstacles to studying laboratory-related adverse events, which must be overcome to carry out quality improvement projects aimed at reducing these events. The first obstacle is that most laboratories do not collect patient outcome data related to laboratory errors. These data are needed to understand the clinical consequences of laboratory error and to prioritize error reduction measures. The second is the practical challenge of detecting the relatively few cases of laboratory-related adverse events among the large number of tests performed. This obstacle is largely due to the lack of effective, rapid screening methods that laboratory personnel can apply to potential cases.Sources of poten...

Context.-Tests that are performed outside of the ordering institution, send-out tests, represent an area of risk to patients because of complexity associated with sending tests out. Risks related to send-out tests include increased number of handoffs, ordering the wrong or unnecessary test, specimen delays, data entry errors, preventable delays in reporting and acknowledging results, and excess financial liability. Many of the most expensive and most misunderstood tests are send-out genetic tests.Objective.-To design and develop an active utilization management program to reduce the risk to patients and improve value of genetic send-out tests.Design.-Send-out test requests that met defined criteria were reviewed by a rotating team of doctoral-level consultants and a genetic counselor in a pediatric tertiary care center.Results.-Two hundred fifty-one cases were reviewed during an 8-month period. After review, nearly onequarter of genetic test requests were modified in the downward direction, saving a total of 2% of the entire send-out bill and 19% of the test requests under management. Ultimately, these savings were passed on to patients.Conclusions.-Implementing an active utilization strategy for expensive send-out tests can be achieved with minimal technical resources and results in improved value of testing to patients.

An electrogenic Na+/HCO3- cotransport system was identified and characterized in freshly dissociated salamander Müller (glial) cells. Under voltage-clamp, these cells generated an outward current when external HCO3- concentration [( HCO3-]o) was raised. This current was Na(+)-dependent, Cl(-)-independent, and was blocked by the stilbenes 4,4'-diisothiocyanato-stilbene-2,2'-disulfonate (DIDS) and 4,4'-dinitrostilbene-2,2'-disulfonate (DNDS), and by harmaline, demonstrating that the current was generated by a Na+/HCO3- cotransport system. Substantially larger currents were evoked when [HCO3-]o was raised at the Müller cell endfoot as compared to other cell regions, indicating that cotransporter sites are localized preferentially to the endfoot. The reversal potential of the current, which varied as a function of HCO3- and Na+ transmembrane gradients, indicated that the cotransporter has a HCO3-:Na+ stoichiometry of 3:1.