An initial investigation into an organ transplant scandal last month points to serious problems in administrative protocol at the hospitals involved, Control Yuan member Yin Jeo-chen (尹祚芊) said on Wednesday.
With the medical technologist and organ transplant coordinator involved in the transplantation of organs from a donor with HIV to five patients at two hospitals making contradictory claims, investigators are worried that as time passes, it will become more difficult to learn what happened.
“One of them said ‘I misheard the results,’ and the other insists ‘that’s what I said,’” Yin said. “It is difficult to determine whether one misheard, or the other misspoke. We can no longer determine who is right or wrong anymore.”
Their claims point to serious problems in hospital transplant protocol, Yin added.
The five transplants — four by National Taiwan University Hospital (NTUH) and one by National Cheng Kung University Hospital — were performed on Aug. 24. Prior to the operations, the NTUH transplant team relied only on communication by telephone to get the results of HIV tests on organs for transplant, and it thought it was given a green light when in fact the organs had tested positive for the virus. The Cheng Kung team took the NTUH team’s word that the organs had been cleared and went ahead with its heart transplant.
“Why didn’t any physician check the written reports before surgery?” Yin said. “How can the confirmation procedure simply be one person reading off the results, and the other listening?”
Yin, who volunteered to join the Department of Health’s special investigation team for the incident, has a doctorate in nursing and is the second vice president of the International Council of Nurses.
The team will be holding meetings with other organ transplant experts and hospitals. Doctors and department officials involved in the case will be questioned to identify loopholes and flaws in the organ transplant procedure, Yin said.
The investigation team has promised to publish results of the probe within a month.
The department said on Aug. 27 that the five patients were at risk of contracting AIDS after receiving the organ transplants.
The 37-year-old organ donor from Hsinchu was registered in Taipei as an HIV patient and had been receiving treatment in Taipei before being transferred to Hsinchu. His organs were donated by his family after he accidentally fell from a building on Aug. 24.
Hospitals cannot know beforehand whether a donor is a HIV carrier because of privacy protection concerns, said Hung Chien-ching, an attending physician at NTUH’s infectious disease department, on Aug. 28.
According to a report by the Chinese-language Liberty Times (the Taipei Times’s sister paper) on Aug. 30, Yin has suggested that people who were HIV-positive should have their condition stated on their health cards. He said this would not affect patient’s privacy but it would help prevent such a tragedy from happening again.
However, National Tsing Hua University Institute of Sociology assistant professor Chen Ming-chi (陳明祺) said that such measures would make it even more difficult for people with AIDS/HIV to receive medical care because they would be discriminated against and turned down by hospitals and clinics out of safety concerns.
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