The head of an organ transplant task force at National Taiwan University Hospital (NTUH) has resigned to take the blame for the hospital’s recent mistake of transplanting organs from an HIV-positive donor into five patients.
“I should be held responsible for the error,” Ko Wen-che (柯文哲) said yesterday.
Ko, known as Taiwan’s father of extracorporeal membrane oxygenation treatment, was responsible for forming and managing the hospital’s organ transplant task force. He also wrote the guidelines for its transplant team.
Surgeon Chou Nai-kuan (周迺寬) will take over as the new leader of the task force.
On Saturday, the hospital admitted that its medical team did not follow standard operation procedures while carrying out organ transplants on Aug. 24. The team failed to check the donor’s HIV test results on a computer before transplanting organs into four patients. Instead, they relied on information passed on by their organ transplant coordinator, who mistook the English word “reactive” for “non-reactive” while listening to test results over the telephone.
NTUH sent the donor’s heart to National Cheng Kung University Hospital, where it was transplanted into a fifth patient.
The incidents marked the first time that Taiwanese organ transplants might lead to recipients acquiring HIV, the Department of Health said.
To prevent errors from happening in the future, the department on Wednesday said transplant team members at NTUH would be required to speak in Chinese when referring to HIV-test results.
Shih Chung-liang (石崇良), director of the Bureau of Medical Affairs, said non-reactive would be referred to as “yin” and reactive as “yang” in conversations about test results, adding the new regulation would only apply to NTUH.
The test results in document form would remain in English, he said.
The Department of Health said later yesterday that the five patients involved in the case would not find out if they have been infected with HIV until May next year at the earliest.
Since Monday, all five, with the agreement of their families, have been taking post-exposure anti-viral medication, Shih said.
Some of the recipients have not been informed of their situation and all will need to take prophylactic medication for at least three months, he said, adding that any HIV infection could not be confirmed until six months after the end of the drug regimen.
“During the medication period, we will keep a close eye on the viral load and whether there is any occurrence of anti-viral resistance,” Shih said.
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