Fri, Sep 30, 2011 page2

• Transplant probe blames NTUH

  CATALOG OF ERRORS: The investigation into how five patients received organs from an HIV-infected donor revealed a number of administrative and human mistakes

  • Staff Writer, with CNA
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  The probe into the transplant of organs from an HIV-positive donor places the blame on National Taiwan University Hospital (NTUH) for two fundamental administrative faults, Deputy Minister of Health Chiang Hung-che (江宏哲) said yesterday.

  Chiang made the remarks at a press conference held by a group of Chinese Nationalist Party (KMT) lawmakers to publish the results of the investigation. He said the hospital has been ordered to make improvements within one month.

  Administrative errors include the exclusion of the organ transplant project from the normal hospital management system and a lack of actual participation from the responsible physician in the organ transplant procedure, Chiang said.

  Medical processes, such as organ tests, examinations, listing and billing, were all entrusted to other staff and communications throughout the organ transplant procedure were plagued with problems, -Chiang said.

  The standard operating procedure was incomplete, he added.

  Another serious problem was that NTUH did not implement a notification system for abnormal risks or important test results, -Chiang said.

  Most hospitals send a text message to the doctor or team in charge to inform them of such risks or results, but NTUH medical staff had failed to do so in the Aug. 24 transplants, Chiang said.

  To eliminate human error, the Department of Health investigative report suggested that NTUH should enforce training for organ transplant and donation teams and strengthen team cooperation, and that doctors responsible should be held accountable and be actively involved in the decisionmaking process.

  The report also recommended the hospital organize manpower in accordance with workload and treat staff reasonably. A team of experts would check the hospital’s progress in a month, Chiang said.

  “I am prepared to go to jail,” said Ko Wen-je (柯文哲), the intensive care unit chief of NTUH and former director of the hospital’s organ transplant task force.

  Ko said it is unlikely that the transplant surgeons would be held accountable under the current system.

  While the hospital is reluctant to accept the department’s rulings, the recent changes made to organ procurement protocol by the department indicates the system was faulty, Ko said.

  Ko said that since the incident occurred last month, there has been public outrage which has prevented people from being able to treat the incident with a “no blame” attitude.

  As with any dispute, Taiwan always turns to the criminal law system, Ko said.

  “Medical practice is becoming the industry with the highest crime rate,” Ko said.

  The incident has put the brakes on legal amendments to “decriminalize medical errors” in the legislature, Ko said.

  NTUH and National Cheng Kung University Hospital have each been fined NT$150,000 (US$5,170) over the blunder.

  According to the Medical Care Act (醫療法), hospitals can be further fined NT$50,000 to NT$500,000 for causing the death of a patient, said Shih Chung-liang (石崇良), director of the Bureau of Medical Affairs.

  Nobody has died in the case.

  The health department said it would hold a meeting with experts at the end of the year to discuss the organ procurement network and organ transplant procedures, and to re-assess organ allocation policies. The department would also be reviewing transplant hospitals and organ transplant doctors’ qualifications, and formulating an exit policy, it added.

  The department announced on Aug. 27 that five patients have a high risk of contracting HIV after receiving organ transplants performed by NTUH from an HIV-positive donor.

  The 37-year-old donor from Hsinchu was registered in Taipei as a 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.

  So far the five organ recipients and transplant team members have tested HIV-negative. The victims have received HIV preventive medication and they have been put under observation for a year, Chiang said.
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