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一次移植，52人可能染艾滋（热点聚焦）
2011年09月06日01:08来源：环球时报-生命时报
台湾大学医院日前发生一起重大医疗事故，院方误将一名艾滋病感染者的器官移植给5名病患。目前接受移植手术的5人都已验出艾滋病病毒，其中换肺的病患病毒浓度最高。台湾“卫生署”已成立专案小组负责处理事故，台湾检察机关也已介入调查。
据了解，捐赠器官者是一名37岁男子，8月24日因头部外伤送到台湾新竹市南门综合医院急救，次日宣告不治。家属在不知男子是艾滋病感染者的情况下，联络台大医院器官捐赠小组。器官捐赠协调人员为抢时间，和台大检验人员仅以电话确认结果，却不幸混淆了艾滋病检验结果的“阳性”与“非阳性”，且检验人员也未做二次确认就进行了移植手术。该名艾滋病患者的心脏、肝脏、肺脏和两颗肾脏分别捐赠给了5名病患，其中心脏送到位于台南的成功大学医院进行移植，其他4起手术都在台大医院进行。等到器官移植手术完成，协调者收集检验报告纸本资料时，看到捐赠者的艾滋病检验结果竟然是“阳性”，才发现大事不妙，紧急通知移植团队，但为时已晚。
事件发生后，原本沉浸在获得器官重获新生喜悦中的移植患者和家属，全都懵了。患者当日起开始接受艾滋病药物治疗。参与移植的47位医护人员也面临着感染艾滋病毒的风险，他们也被进行感染追踪及心理辅导。捐赠者的母亲在获悉此事后相当内疚自责。她表示，不知道儿子患有艾滋病，“原本只是想替儿子做好事、积功德，没想到反而害了人，实在对不起。”
事故发生后，批评的声浪此起彼伏。台大医院发言人谭庆鼎于8月27日晚紧急召开记者会，公布事故原因并向病患家属和社会大众道歉。8月30日，台大医院院长陈明丰首次出面道歉，强调“该负责的就要负责”。
台湾“卫生署”医事处长石崇良也在8月31日公布了此次台大医院的三大问题：一是检验员与协调人员口头沟通失误，二是未再确认书面报告或在系统上确认数值，三是移植小组未再确认检验结果。日前，台湾“卫生署”已根据相关法律，对台大、成大两家医院各开出15万新台币的罚单，同时责成两家医院迅速订出受害病患的后续照顾计划，包括赔偿金额等。此外，最终确认受捐者感染了艾滋病后，失职医护人员将面临3—10年的有期徒刑。
编后：生命来不得半点马虎，可台湾这起重大医疗事故，绝不止马虎这么简单。捐赠者想积德行善，受捐者盼重塑生命，行医者愿济世救人。可如此的美满，竟被一个个漏洞无情粉碎了。如果所有人按流程办事，即使第一道口头确认出现了闪失，第二道书面确认、第三道移植小组再确认，都可以把事故挡在门外。但可惜，无一人再做理会，最终错失改正之机。我们只希望，医护人员能够在管理上再到位些，操作中再细致些，思想上再严谨些，将医疗事故减至最低，医患矛盾永不再来。
艾滋病不治会早死，早治才康复 艾滋病不治会早死，早治才康复 艾滋病不治会早死，早治才康复 艾滋病不治会早死，早治才康复
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| 图示∶2011年5月正式出版的《中国特色医疗金鉴》登载的刘君主任及其机构事迹 |
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A transplant, 52 HIV may dye (Spotlight)
At 01:08 on September 6, 2011 Source: Global Times - Life Times
Taiwan University Hospital, a major medical incident occurred a few days ago, the hospital mistakenly an AIDS-infected persons to the five organ transplant patients. Currently receiving transplants of five people have tested HIV, lung disease for which the highest concentration of the virus. Taiwan, "Health Department" has set up ad hoc group to deal with accidents, Taiwan prosecutors have also been involved in the investigation.
It is understood that the donor was a 37-year-old man, Aug. 24 due to head trauma to the Hsinchu City, Taiwan South Gate General Hospital, pronounced dead the next day. Families living with HIV do not know the man is the case, contact the National Taiwan University Hospital organ donation groups. Organ donation coordinator for the race against time, and the National Taiwan inspectors only call to confirm the results, but unfortunately confused the HIV test results "positive" and "non-positive", and the inspectors have not done it for a second transplant to confirm . The AIDS heart, liver, lungs and two kidneys were donated to five patients, of which the success of the heart to the University Hospital in Tainan for transplant, the other four are from the National Taiwan University Hospital for surgery. Until the completion of organ transplants, coordinator paper inspection reports to collect information, see the donor's HIV test results turned out to be "positive", only to find that something urgent notice transplant team, but it was too late.
After the incident, had immersed in the joy of rebirth to obtain organ transplant patients and their families, all senseless. Patients receiving AIDS drugs from the date of starting treatment. 47 health care workers involved in transplantation are also facing the risk of HIV infection, they were tracked for infection and psychological counseling. The donor's mother was informed that the matter quite guilty remorse. She said her son did not know people with AIDS, "was originally just want to make his son to do good, the plot merit, but did not expect harm to people, I'm terribly sorry."
After the accident, considerable criticism after another. National Taiwan University Hospital spokesman Ching-Ting Tan on the evening of August 27, held an emergency press conference to announce the cause of the accident to the patient's family and the community an apology. August 30, the first Ming-Fong Chen National Taiwan University Hospital apology, stressing that "the responsibility must be responsible."
Taiwan, "Department of Health," Medical Director Dan Chongliang also announced August 31 the National Taiwan University Hospital on three major issues: First, inspectors and coordinators verbal communication errors, the second is not re-confirm in writing to confirm the report or on the system value, third transplant team did not confirm the test results again. Recently, Taiwan's "DH" in accordance with relevant laws, National Taiwan University, National Cheng Kung University Hospital, two NT $ 150,000 each out of the ticket, and instructed the two hospital patients suffer rapid set up care plans, including compensation the amount of money. In addition, the final confirmation by the donors infected with HIV, the dereliction of duty staff will face 3-10 years in prison.
Editor: Life careless, Taiwan, which can play a major medical, far more than sloppy that simple. Donors to good deeds, by the donors hope reshape lives, practitioners willing to Saving the world. Can be so happy, was hit by a ruthless crushing of a loophole. If everyone acted according to the process, even if the first accident occurred verbal confirmation, the second written confirmation, the third transplant team then confirmed that the accident could get in the door. Unfortunately, people do care about no one, missed the final correction of the machine. We only hope that medical staff can then place these in the management, operation, and then more detailed, rigorous thinking and then some, to minimize medical, doctor-patient conflicts and never come back.
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