Human error results in organs from a person with HIV being used in three transplants

Three organ recipients in Italy became infected with HIV after they were accidentally provided with organs from an HIV-positive individual. The patients received the organs after a hospital employee accidentally wrote “negative” instead of “positive” after reading HIV test results. The incident is reported in the March 9^th edition of Eurosurveillance Weekly Release.

The infections occurred in February 2007. The organ donor was a woman in her 40s who died of a brain haemorrhage. Her family consented to the harvesting of her organs not knowing she was infected with HIV. Three organs from the woman (both kidneys and the liver) were transplanted into three separate individuals.

Further blood tests performed at tissue banks showed that the organs had been obtained from an HIV-positive donor. The centre that carried out the transplants was alerted, but not until five days after the procedures had been undertaken. Part of this delay was because the test results were faxed to key personnel on a Saturday morning and were therefore not received until the following Monday.

The three organ recipients were immediately told that the donor was HIV-positive and, according to the Eurosurveillance report, the three patients are now receiving care from “an international task-force comprised of leading experts in infectious diseases.”

All three organ recipients have tested HIV-positive and are receiving potent anti-HIV therapy. Italian health officials have said that it will take “about a year to make a general commentary on their health condition.”

A commission appointed to investigate the incident blamed it on human error and negligence. They have proposed the introduction of a series of precautionary measures when testing the blood of donors for HIV, hepatitis B and hepatitis C, including:

• Cross-checking of results to ensure their accuracy.
• Using electronic methods to transfer test results, therefore eliminating the manual transcription of data.
• Using clearly identifiable computerised graphic symbols to indicate an organ donor’s suitability.
• The use of detailed immunological and virological results from tests.
• Improved laboratory facilities and training.