Clipping Board » Medical Affairs and Administration ─ Medical system, pharmaceuticals, and medical community-related reports
China Broadcasting Corporation 2011/08/29
A major error occurred at National Taiwan University Hospital involving the transplantation of organs from an HIV-positive donor. The preliminary report indicates that the most critical mistake stemmed from communication failures. The test results were not properly attached to the patient's medical records. After completing the transplant, the surgical team rushed to Taitung to assist with another operation. It wasn’t until 48 hours later, when they reviewed the patient's records, that they realized the donor was HIV-positive. Experts believe that to prevent similar incidents, specialized hospitals must improve their systems, strengthen communication and mutual reminders, and urgently call for government funding to ensure sufficient manpower for proper organ transplantation. (Reported by Chen Yihua)
The fatal mistake of transplanting organs from an HIV-positive patient to recipients at NTU Hospital has left domestic transplant authority and chairman of the Taiwan Society of Transplantation, Li Bozhang, deeply regretful after reviewing the preliminary report. He emphasized that no one acted intentionally, but verbal miscommunication led to this grave oversight.
The report revealed that during a critical moment of communication, the lab technician and the transplant coordinator exchanged test results over the phone. Due to the technician’s calm tone and similar-sounding terms, the coordinator may have misunderstood. "When the data was sent to the email, it was clearly visible as 'reactive.' But verbally, when I said 'Hepatitis B negative, Hepatitis C negative, HIV reactive,' if someone wasn’t paying close attention to the English terms, 'reactive' could sound like 'negative' because both end with 'tive.'"
Additionally, what was even more shocking was that the transplant team only discovered the donor’s medical records and written reports two days after the surgery, by which time the situation had become severe. "Because the written reports were only printed out after the surgeries were completed and the team returned to the office, they realized the mistake. Due to the hectic schedule, such a serious incident occurred. The surgery began last Wednesday afternoon, continued through Thursday, and it wasn’t until Friday night that they saw the written report. Therefore, the system must be revised to ensure each hospital has a robust protocol."
Li Bozhang suggested that using Chinese in medical records could be a feasible solution. Beyond improving systems, the 12 designated transplant hospitals in Taiwan must prioritize communication and mutual reminders. Given the difficulty in cultivating talent and limited resources, he urgently called for the government to invest more funding and manpower to ensure the proper execution of organ transplants.
Source: http://tw. news. yahoo. com/ article/ url/ d/ a/ 110829/ 1/ 2xqpn. html
HIV-infected Organ Transplant Error Discovered after 48 Hours
A major error occurred at National Taiwan University Hospital involving the transplantation of organs from an HIV-positive donor. The preliminary report indicates that the most critical mistake stemmed from communication failures. The test results were not properly attached to the patient's medical records. After completing the transplant, the surgical team rushed to Taitung to assist with another operation. It wasn’t until 48 hours later, when they reviewed the patient's records, that they realized the donor was HIV-positive. Experts believe that to prevent similar incidents, specialized hospitals must improve their systems, strengthen communication and mutual reminders, and urgently call for government funding to ensure sufficient manpower for proper organ transplantation. (Reported by Chen Yihua)
The fatal mistake of transplanting organs from an HIV-positive patient to recipients at NTU Hospital has left domestic transplant authority and chairman of the Taiwan Society of Transplantation, Li Bozhang, deeply regretful after reviewing the preliminary report. He emphasized that no one acted intentionally, but verbal miscommunication led to this grave oversight.
The report revealed that during a critical moment of communication, the lab technician and the transplant coordinator exchanged test results over the phone. Due to the technician’s calm tone and similar-sounding terms, the coordinator may have misunderstood. "When the data was sent to the email, it was clearly visible as 'reactive.' But verbally, when I said 'Hepatitis B negative, Hepatitis C negative, HIV reactive,' if someone wasn’t paying close attention to the English terms, 'reactive' could sound like 'negative' because both end with 'tive.'"
Additionally, what was even more shocking was that the transplant team only discovered the donor’s medical records and written reports two days after the surgery, by which time the situation had become severe. "Because the written reports were only printed out after the surgeries were completed and the team returned to the office, they realized the mistake. Due to the hectic schedule, such a serious incident occurred. The surgery began last Wednesday afternoon, continued through Thursday, and it wasn’t until Friday night that they saw the written report. Therefore, the system must be revised to ensure each hospital has a robust protocol."
Li Bozhang suggested that using Chinese in medical records could be a feasible solution. Beyond improving systems, the 12 designated transplant hospitals in Taiwan must prioritize communication and mutual reminders. Given the difficulty in cultivating talent and limited resources, he urgently called for the government to invest more funding and manpower to ensure the proper execution of organ transplants.
Source: http://tw. news. yahoo. com/ article/ url/ d/ a/ 110829/ 1/ 2xqpn. html