Taipei, Aug. 29 (CNA) The Department of Health indicated Monday that the surgeons who conducted transplants of the five organs from a HIV-positive donor must be held responsible for not checking medical records thoroughly before the procedure.
In reality, many steps went wrong for such an error to occur. The coordinator of the case did not comprehend the medical inspector, who did the pre-surgical tests to determine that the organs came from an HIV-carrier. The coordinator then imported wrong test results to the Taiwan Organ Registry and Sharing Center.
But according to Shih Chung-liang, who heads the Bureau of Medical Affairs under the Department of Health, the surgeon who took out the organs from the donor and those who implanted the problematic organs into the five recipients should take partial responsibility.
"Of course we will not" put all the blame on the coordinator alone, he said.
Shih explained that surgeons in charge should take "time-out" before transplant operations to double-check and certify the identity of the donor, the surgical parts, the surgical methods, and important test results.
The transplant team at National Taiwan University Hospital (NTUH) and that of National Cheng Kung University (NCKU) Hospital shared the same mistake -- they both failed to engage in the final checks, Shih said.
On Aug. 27, NTUH, one of Taiwan's most prestigious health care institutions, admitted that its medical team did not follow standard operation procedure in carrying out 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, they got the information they required over the phone, which resulted in the team thinking the organs were HIV-free.
NTUH also sent the donor's heart to NCKU, and it was used in a fifth transplant at NCKU Hospital in Tainan, southern Taiwan.
According to the DOH, internal investigative reports of the two hospitals on the serious medical flaw will not be produced until the next day.
Shih stated that after receiving the reports, a DOH expert team will present the results of their probe within 10-14 days before deciding what punishments will be imposed upon those who are held responsible.
Meanwhile, the DOH has set a new rule for future transplants.
Before performing any organ transplant, medical personnel must strictly follow two procedures of confirmation -- announcing and repeating blood test results of donors on telephone, and checking on written documents of the test results -- to prevent possible communication mistakes, Shih said.
(By Chen Ching-fan and Elizabeth Hsu)