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Taiwan: 5 Get Organs With H.I.V., Transplant Error
 
 
  Aug 29 2011, By THE ASSOCIATED PRESS
 
One of Taiwan's best-regarded hospitals said HIV-infected organs were mistakenly transplanted into five patients after a staff member misheard the donor's test results over the telephone. The five are now being treated with anti-AIDS drugs, an official at the National Taiwan University Hospital in Taipei said Monday. The hospital said on its Web site that the mistake occurred because a staff member mistakenly believed he heard the English word "nonreactive" concerning the donor's standard H.I.V. test. The donor's heart, liver, lungs and two kidneys were transplanted into separate patients on the same day.
 
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huffingtonpost.com Aug 29 2011 -
 
The donor was a 37-year-old man who fell into a coma on Aug. 24 and his heart, liver, lungs and two kidneys were transplanted to five patients on the same day. NTUH said it transplanted four organs and the heart transplant was conducted at another hospital.
 
The donor's mother, who was not identified, told cable news stations that she felt terrible about the transplants and had not been aware of her son's ailment. She said he died after "falling from a high spot," without providing details. Yao Ke-wu, who heads the health department of Hsinchu city, where the donor resided, decried the NTUH transplants as "appalling negligence."
 
He said NTUH staffers could have avoided the mistake by asking his department about the donor's medical history in advance and deplored that such inquiries were not mandatory in Taiwan.
 
Yao said the five organ receivers will very likely contract HIV and their treatment will be complicated because they also have to take medication to avoid rejection of the new organs.
 
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Taiwan "AIDS organ" scandal: 52 might be infected with HIV
 
http://news.xinhuanet.com
 
BEIJING, Aug. 31 (Xinhuanet) -- In Taiwan, a man affected by HIV AIDS died in a car accident and subsequently had his organs donated to five other patients in need. The consequences were horrifying, 52 people, including 5 organ receivers and 47 medical staffs are suspected of being infected with HIV.
 
Taiwan's Department of Health held a press conference on Monday in the hope of easing the scare and anger over this unprecedented medical scandal. The department has set up three special independent groups and started investigations into the incident at the Taiwan hospital. The initial result is likely to be known next week.
 
Meanwhile, operations of organ transplants have been halted at Taiwan University Hospital. More than 1,800 patients waiting for organ transplants are being transferred to other hospitals.
 
The public is applying great pressure on the hospital and the department of health. The head of the department was surrounded by media.
 
Chiu Wenta, administrator of Taiwan's Dept. of Health, said, "I feel extremely regretful and sad over this accident. The priority now is to care for the organ receivers. We need to form a caring group including social workers, psychologists and doctors. then we will need to find out what really went wrong and who is responsible for this tragedy."
 
An initial report filed by the hospital shows the incident may be related to misunderstood communications in phone calls between the hospital's laboratories and coordinators of the organ transplant operation. The hospital itself is currently undertaking a thorough investigation.
 
According to local media, 26 medical staff including doctors and nurses who were involved have had negative results from HIV tests. However, there is a 6-month open window period for HIV affections so it may still be too early for the final results.
 
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Fears for patients in HIV donor scandal
 
8/30/2011
http://www.chinadaily.com.cn
 
One of five patients who mistakenly received transplanted organs from a HIV-positive donor may have contracted the disease, cnr.cn reported Tuesday citing medics.
 
The female patient, who underwent heart transplant surgery, is among five patients who received organs from one infected donor in Taiwan's first ever AIDS organ transplant scandal at the National Taiwan University Hospital and Cheng Kung University Hospital.
 
The woman is currently recovering in intensive care unaware of the error. The plight of the four other patients remains unknown. It is believed at least one patient has been informed of the mistake and collapsed upon hearing the news. On Tuesday the Taipei Prosecutors Office assigned a prosecutor with a medical background to investigate the case.
 
Medics face three to ten years in jail if it is proven the patients contracted HIV because of the flawed transplant which was exposed on August 27.
 
The family of the donor decided to offer his organs after he was pronounced brain dead following a fall from a ladder at work. They were not aware he had AIDS.
 
The National Taiwan University hospital removed his heart, liver, lung and two kidneys and performed four organ transplant surgeries, the heart, the fifth, was sent to the Cheng Kung University Hospital.
 
The National Taiwan University Hospital said it tested the donor's blood and found him HIV positive before the surgery, but the message was wrongly received by the lab members in both hospitals.
 
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Activists staunchly oppose HIV status on health cards
 
2011/08/31 http://focustaiwan.tw
 
Taipei, Aug. 31 (CNA) HIV/AIDS activist groups protested against the proposal Wednesday to put a person's HIV/AIDS status on their health insurance card, arguing the added information does not ensure the safety of donated organs.
 
The remarks were made five days after two of Taiwan's most prestigious health care institutions -- National Taiwan University Hospital (NTUH) and National Cheng Kung University Hospital (NCKUH) -- mistakenly transplanted organs from a HIV-infected donor into five individuals.
 
Since then, a proposal is being considered by several legislators to add HIV/AIDS status to the health insurance cards that almost all Taiwanese citizens and residents carry to access National Health Insurance.
 
"Noting the status is of no help in preventing donor recipients from possible infection," said Ivory Lin, secretary-general of the Persons with HIV/AIDS Rights Advocacy Association of Taiwan.
 
Many potential donors are not aware of their HIV status, so even if the proposal is adopted by the government, hospitals performing the transplants still need to run on-site HIV tests to make sure the organs are actually HIV-free, she said.
 
Furthermore, Lin said such a practice could further stigmatize HIV-positive individuals and jeopardize a patient's right to medical treatment.
 
As many as 25 percent of those who are HIV-positive, after informing medical personnel of their health condition, are denied medical services, said Paul Hsu, secretary-general of the Taiwan Lourdes Association, a local Catholic organization that helps people living with HIV/AIDS.
 
"The privacy and rights of those with HIV/AIDS and the safety of organ recipients and medical staff are not two opposing issues," said a man who identified himself as Goffy. He is a well-known AIDS activist from Taiwan Tong-zhi Hotline Association.
 
A sound health care system should not sacrifice either value, he said.
 
The public outcry of fear following the HIV organ transplant mistake reflects a society that still lacks sufficient knowledge of the disease, Goffy said.
 
"People still have the stereotype that people who are HIV-positive cannot lead a normal life and that getting the disease means the end of the world," said Goffy. He urged the end of widespread panic over HIV/AIDS issues.
 
On Aug. 27, NTUH admitted that its medical team did not follow standard operating procedure in carrying out the organ transplants.
 
The team failed to check test results on the computer before transplanting organs from an HIV-infected donor into four patients Aug. 24. Instead, the staff received test information over the phone, and miscommunication resulted in the team thinking the organs were HIV-free.
 
NTUH also sent the donor's heart to NCKUH, which was given to a fifth patient.
 
It marked the first time in Taiwan that organ transplants might lead to the recipients acquiring HIV, according to the Department of Health (DOH).
 
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China Times: NTUH explanation needed as soon as possible
 
2011/08/31 12:26:23
http://focustaiwan.tw
 
Last week, National Taiwan University Hospital (NTUH) was found to have committed a serious mistake that allowed organs from a HIV-infected donor to be transplanted into five patients.
 
The severe flaw was only discovered two days after the procedures were done. And three more days passed before NTUH Superintendent Chen Ming-fong appeared publicly to offer an apology, stressing that the hospital would punish the involved staff and would not evade its responsibility. Is that really a "responsible" attitude?
 
The mistake was traced to a communication failure between a lab technician and a coordinator with the hospital's organ transplant task force, in which the donor's "HIV reactive" result was misunderstood as meaning "HIV negative."
 
These two individuals involved certainly need to take direct responsibility, but there was also managerial negligence at the hospital because it failed to set up a stringent gatekeeper mechanism.
 
Meanwhile, Department of Health (DOH) Minister Chiu Wen-ta simply expressed "regret" over the incident and did not mention issues such as punishment for the hospital and compensation for the victims.
 
This is totally unacceptable. Although NTUH is one of the country's leading hospitals in the area of organ transplants, there are still 1,800 patients on organ waiting lists, meaning the DOH cannot let NTUH off the hook.
 
If necessary, the DOH should also help transfer the four people who received organ transplants at NTUH to another hospital for follow-up care. This would help ease any possible concerns over whether to sue NTUH because their lives were still in the hospital's hands.
 
A more important matter is for NTUH's management to give the public an explanation as to how it will compensate the victims, punish those involved, and take responsibility without further delay.
 
Hospitals to be fined NT$150,000 each for flawed transplants
 
http://focustaiwan.tw
 
2011/08/30 22:49:22 Taipei, Aug. 30 (CNA) The two hospitals involved in mistakenly transplanting organs from an HIV-infected donor into five patients will be fined NT$150,000 (US$5,172.42) each as an initial penalty for their negligence, the Department of Health (DOH) said Tuesday.
 
The Taipei and Tainan city governments have been asked to issue the fines the following day to National Taiwan University Hospital (NTUH) and National Cheng Kung University Hospital (NCKUH), respectively, DOH spokesman Wang Che-chao said.
 
The punitive decision was taken during a meeting of a task force formed earlier in the day to investigate the case, the first of its kind ever to come to light in Taiwan, Wang said.
 
The fine was meted out in accordance with Article 11 of the HIV Infection Control Patient Rights Protection Act, which requires medical institutions to conduct HIV tests on potential donors before proceeding with any organ or tissue transplant.
 
Violators can be slapped with a fine ranging between NT$30,000 (US$1,034.48) and NT$150,000 in accordance with Article 22 of the act, Wang said.
 
"Follow-up punishment can be laid down in tandemn with the progress of subsequent investigations," he added.
 
The Taipei Prosecutor's Office also began to investigate the case Tuesday.
 
The flawed transplants -- four by NTUH and one at NCKUH -- were performed on Aug. 24.
 
The hospitals only realized two days later that the donor was an HIV-carrier. Prior to the operations, the NTUH transplant team relied only on a phone communication to get the results of HIV tests on the organs, and it thought it was given a green light when in fact the organs had tested positive for the virus.
 
NCKUH took the NTUH transplant team's word that the organs were clean and went ahead with its heart transplant.
 
NTUH admitted on Aug. 27 that its medical team did not follow standard operating procedures in the case and should have checked for the test results on the computer before proceeding.
 
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Prosecutor begins probes into flawed organ transplants
 
2011/08/30 15:19:18
 
Aug. 30 (CNA) The Taipei Prosecutors Office said Tuesday it has assigned a prosecutor with a medical education background to investigate a case involving the transplants of organs from a single HIV-infected donor into five patients at two local hospitals.
 
Wang Wen-teh, spokesman for the office, said the case might be an indictable offense based on Article 11 of the HIV Infection Control and Patient Rights Protection Act, which requires medical institutions to conduct HIV tests before proceeding with any organ or tissue transplant.
 
Violators can be slapped with a fine ranging between NT$30,000 (US$1,034.48) and NT$150,000 in accordance with Article 22 of the act, Wang said.
 
If a flawed transplant leads to a recipient falling victim to HIV infection, those involved in such an operation could be given jail terms of between three to 10 years, he added.
 
In the country's first-ever case involving the transplant of organs from an HIV carrier, hospitals will only be fined if nobody is confirmed to be infected with HIV from the procedures, Wang explained.
 
"While it takes time to determine whether anybody has contracted HIV in this case, we need to start the investigation right away," Wang said.
 
The prosecutors office has asked the DOH to provide all relevant data and information as health-care institutions are obligated to inform the DOH of organ donation and transplant cases, he said.
 
"We need to check medical institutions' regular standard operating procedures (SOP) for organ donations and transplants," Wang said, adding that those who will be summoned for questioning include the individuals responsible for removing organs, reporting the HIV test results, verifying the results and approving the transplant surgery.
 
Lu Chun-ju, a graduate of National Taiwan University's Department of Medical Technology who has been assigned to investigate the case, said no specific individuals have so far been targeted as suspects.
 
"For the moment, I will focus on collecting facts related to the incident," he said.
 
Meanwhile, he said, patients or their families are entitled to file damage suits against the medical institution.
 
The flawed transplants -- four by National Taiwan University Hospital (NTUH) and one at National Cheng Kung University Hospital (NCKUH) -- were performed on Aug. 24. The hospitals only realized two days later that the donor was an HIV-carrier.
 
Prior to the operations, the NTUH transplant team relied only on a phone communication to get the results of HIV tests on the organs, and it thought it was given a green light when in fact the organs had tested positive for the virus.
 
NCKUH took the NTUH transplant team's word that the organs were clean and went ahead with its heart transplant.
 
NTUH admitted on Aug. 27 that its medical team did not follow standard operating procedures in the case and should have checked for the test results on the computer before proceeding.
 
 
 
 
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