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Taiwan first transplanted human organs in 1969 in a case that was
also Asia's first kidney transplant. Modern transplant medicine in Taiwan
has developed to global standards since then, and many transplant teams in
Taiwan have worldwide reputations for quality and excellence.
Unfortunately, a patient safety event happened in Taiwan this
August.[1] The family of a man decided to donate his organs
after he fell into a coma, unaware that he was an HIV carrier.
Medical technicians performing standard blood tests found that this
patient was HIV-positive before his organs were harvested. But the message
was wrongly relayed, and doctors carried out several transplant operations
without this knowledge. The donor's heart, liver, lungs and two kidneys
were transplanted to five patients on the same day. After the error was
discovered, anti-HIV medications were prescribed for all organ recipients
within 36 hours after the operations. Recent HIV test reports indicated
negative results for all patients.
A root-cause analysis (RCA) revealed that the coordinator of the
organ procurement organization keyed test results directly into the
transplant center's database after receiving the result from a laboratory
technician via telephone. A communication error led to "reactive" being
misheard as "non-reactive." The information on the test result was not
double-checked, as required by standard procedures. The head of the organ
transplant team failed to verify the donor's HIV test result, and medical
technicians failed to notify the doctors that the donor was HIV-positive.
Following the RCA finding, a forum on organ transplants was held
where hundreds of experts were present and together advised six general
directions for improvement include: 1) reforming Taiwan's organ donation
and transplantation center by recruiting a full-time CEO and a medical
director; 2) merging the various organ procurement systems of different
hospitals into a single comprehensive department; 3) assuring fair and
equitable distribution and optimum utilization of donated organs;
4)improving professionalism of the transplant teams; 5)establishing a
national warning mechanism for HIV/AIDS-infected donors; 6)encouraging
organ donations by all means. Taiwan's Department of Health will adopt the
advice and proceed with timely reforms.
Most errors are committed by hard-working people trying to do the
right thing. This event is a good example. The traditional focus on
identifying who is at fault is a distraction. It is far more productive to
identify error-prone situations and settings, and to implement systems
that prevent errors. However, balancing "no blame" with justice and
accountability in patient safety is a challenge for health officials.[2]
Reference:
1. Parry J. Taiwan transplant team blamed for HIV positive organ
blunder. BMJ 2011; 343:d6523
2. Peled H. Balancing "no blame" with accountability in patient
safety. N Engl J Med. 2011;362(3):275
Competing interests:
No competing interests
17 October 2011
Min-Huei Hsu
Director, Office for Science and Technology Development, Department of Health, Taiwan
Yu-Chuan (Jack) Li, Professor and Dean,College of Medical Science and Technology,Taipei Medical University, Taiwan
Office for Science and Technology Development, Department of Health, Taiwan
Balancing "no blame" with justice and accountability in patient safety
Taiwan first transplanted human organs in 1969 in a case that was
also Asia's first kidney transplant. Modern transplant medicine in Taiwan
has developed to global standards since then, and many transplant teams in
Taiwan have worldwide reputations for quality and excellence.
Unfortunately, a patient safety event happened in Taiwan this
August.[1] The family of a man decided to donate his organs
after he fell into a coma, unaware that he was an HIV carrier.
Medical technicians performing standard blood tests found that this
patient was HIV-positive before his organs were harvested. But the message
was wrongly relayed, and doctors carried out several transplant operations
without this knowledge. The donor's heart, liver, lungs and two kidneys
were transplanted to five patients on the same day. After the error was
discovered, anti-HIV medications were prescribed for all organ recipients
within 36 hours after the operations. Recent HIV test reports indicated
negative results for all patients.
A root-cause analysis (RCA) revealed that the coordinator of the
organ procurement organization keyed test results directly into the
transplant center's database after receiving the result from a laboratory
technician via telephone. A communication error led to "reactive" being
misheard as "non-reactive." The information on the test result was not
double-checked, as required by standard procedures. The head of the organ
transplant team failed to verify the donor's HIV test result, and medical
technicians failed to notify the doctors that the donor was HIV-positive.
Following the RCA finding, a forum on organ transplants was held
where hundreds of experts were present and together advised six general
directions for improvement include: 1) reforming Taiwan's organ donation
and transplantation center by recruiting a full-time CEO and a medical
director; 2) merging the various organ procurement systems of different
hospitals into a single comprehensive department; 3) assuring fair and
equitable distribution and optimum utilization of donated organs;
4)improving professionalism of the transplant teams; 5)establishing a
national warning mechanism for HIV/AIDS-infected donors; 6)encouraging
organ donations by all means. Taiwan's Department of Health will adopt the
advice and proceed with timely reforms.
Most errors are committed by hard-working people trying to do the
right thing. This event is a good example. The traditional focus on
identifying who is at fault is a distraction. It is far more productive to
identify error-prone situations and settings, and to implement systems
that prevent errors. However, balancing "no blame" with justice and
accountability in patient safety is a challenge for health officials.[2]
Reference:
1. Parry J. Taiwan transplant team blamed for HIV positive organ
blunder. BMJ 2011; 343:d6523
2. Peled H. Balancing "no blame" with accountability in patient
safety. N Engl J Med. 2011;362(3):275
Competing interests: No competing interests