When National Taiwan University Hospital (NTUH) and National Cheng Kung University Hospital (NCKUH) gave organ transplants to five people from an HIV-positive donor, they may well have been guilty of committing one of the biggest mistakes in medical history.
On Aug. 24, the donor sustained serious head injuries and neurological tests showed that his Glasgow Coma Scale score — a scale used to determine the conscious state of a person — was three, the lowest possible. His family, who were unaware that the man was HIV-positive, donated his heart, liver, lungs and kidneys for transplant.
According to standard procedures, hospitals are required to test for HIV, hepatitis C and syphilis before accepting an organ for transplant. NTUH followed this process and found that the donor was HIV-positive, but staff on the transplant team only asked for the results over the telephone and misinterpreted the lab’s answer of “reactive” as “non-reactive.”
The head surgeon then went ahead with the transplants without verifying the results a second time and without checking the results on the hospital’s computer system. In addition, the wrong information was relayed to the transplant team at NCKUH, who trusted NTUH when they said the organs were clear.
Only when the test reports were gathered after the transplants had been done was the mistake discovered. The two hospitals were immediately informed and requested to test the patients to see if they had been infected, and to start treatment if required.
These incidents are not only the result of oversights caused by human error, they are also the result of a systemic failure. Five patients who had been given a new lease of life ended up with another potentially deadly threat to their lives, since recipients of HIV-infected organs are almost certain to contract the virus.
This tragedy sets a new world record. Previously, the most serious example of HIV transmission as a result of an organ transplant occurred in the US in 1994, when organs from a donor infected four patients with HIV and hepatitis C. Taiwan has now topped that: not a record to be proud of.
Furthermore, the donor in the US was infected with HIV only after he had signed the organ donor agreement. In this case, the infected donor was not only registered as HIV-positive, the organs also tested positive for the virus. All the preventative measure were in place, but in the end, miscommunication and a lack of verification led to a very serious medical error.
NTUH must shoulder all the responsibility for this incident. The hospital will have to pay compensation, and it will have to take on the responsibility of providing all the victims’ future medical treatment. In terms of medical affairs administration, the Department of Health must find and punish those responsible. If the victims file a lawsuit, medical personnel found guilty of professional oversight can be sent to jail.
NTUH is the nation’s leading hospital and our leader in organ transplants. This fact probably created a feeling of self-satisfaction, which in turn might have led to the lax management and controls that hurt both the patients and the hospital itself.
An outstanding medical team must not only adhere to high medical standards; the members must also be fearless in reviewing and critiquing their own performance and strictly follow standard operating procedures. That is the only way to maintain medical quality and win the public’s trust.