It's been a while since I've last posted something on this blog. Since I have found time to do so, I'm posting something, which I first saw in Twitter, that really struck me. A month ago, news broke that a hospital in Taiwan unintentionally harvested and transplanted HIV-infected organs to 5 patients. Here's an excerpt of the article:
Taiwanese hospitals mistakenly transplant HIV-infected organs
"Doctors at National Taiwan University Hospital (NTUH) in Taipei transplanted the organs of an HIV-infected donor on Wednesday without performing checks, putting five organ transplant recipients at high risk of contracting AIDS, Taiwan's Department of Health (DOH) said Saturday (Aug 27).
Tan Ching-ting, a spokesman for the hospital said at a news conference that its physicians only checked the results of HIV tests with the hospital's laboratory by telephone, leading to a misunderstanding. Transplant team members misheard a member of the lab say the test results were "non-reactive" and proceeded to perform four transplant procedures, Tang said.
A fifth organ was sent to National Cheng Kung University Hospital in Tainan in southern Taiwan, which apparently suffered a similar oversight."
If you're interested in reading the full article yourself, just click here.
Reflecting from the article, a simple read back and/or a written/printed official result that can be e-mailed or faxed might have made the difference. But what's done is done and, as the saying goes, "it's no use crying over spilled milk." Despite the unfortunate circumstance, I commend the health professionals of Taiwan for handling the situation as professionally as possible as well as exerting efforts in providing solutions for the affected patients. Hopefully, everyone who has read the article will learn from the mistakes and it will be the last time we hear of such an occurrence.
This post was not meant to point fingers at anyone but it, hopefully, serves as a reminder that everyone must remain vigilant in terms of documenting any information that might cost the life of a person. The hospital I am currently affiliated with will be re-accredited by the Joint Commission International (JCI) next year. As such, the importance of quality healthcare and patient safety has been constantly emphasized and ingrained in the hearts and minds of the entire hospital community. Everyone in the hospital plays an important role - the hospital managers, the consultants, the residents, the interns, the clerks, the nurses, the administrative staff, the maintenance staff, et cetera - and the success of one is the success of the hospital. The entire accreditation process and provision of excellent and quality health care services remain a joint effort and, as such, I wish that this little nudge reaches the entire hospital community and beyond.
