Five Taiwanese patients recently woke up from transplant surgery with a very different prognosis than what was hoped. Yes, they each had new organs – heart, liver, lungs, and two kidneys – all desperately needed; however, all the organs were donated from an HIV-positive man. One error, resulting from one person taking lab results via telephone (“non-reactive” HIV-test versus “reactive” HIV test) – without a second confirmation or check, which is the hospital’s standard procedure.

It is for this reason that telephone orders for high risk/high alert medications and situations are a thing of the past or at least slowly becoming a thing of the past. There are just too many opportunities for preventable errors. In addition, numerous healthcare organizations are encouraging employees to have a questioning attitude, which encourages double and triple checks. However, processes and procedures are only as good as the people who utilize them appropriately.

"telephone ear piece" by Leo Reynolds via Flickr

While the impacted patients are absolutely the number one priority in this situation, the AP article alluded that the healthcare providers involved were under duress as a result of the situation, as well. I can only imagine. I was involved in a sentinel event, and there is no doubt it changed my thoughts about many issues and greatly impacted my career. I have heard numerous stories of other healthcare professionals – of all disciplines – as well, leaving their respective professions as a result of severe sentinel events. The losses associated with this case will likely continue for quite a while.

Organ donation and transplant are usually filled with so much hope and meaningful continuation of life lost. One moment shattered that. My thoughts are with the five patients and their families. My condolences to the organ donor’s family who not only lost a loved one, but first heard about his HIV-positive diagnosis through this tragedy. I wish the best for all the healthcare providers involved and the millions of others who dedicate their lives to people via professions intolerant of errors.