臺灣重大醫療事故 誤移植艾滋器官給五人

National Taiwan University Hospital transplanted the organs of an HIV-infected donor on Wednesday without realizing it, putting five organ transplant recipients at high risk of contracting AIDS, the Department of Health said yesterday.

The department said it was the first-ever known incident of recipients being exposed to the risk of contracting AIDS because of organ transplants.

The hospital informed the -department of the incident earlier in the day, Centers for Disease Control deputy director Shih Wen-yi (施文儀) said.

Shih said the hospital had offered emergency anti-AIDS medication to the five organ transplant recipients.

The hospital has not issued a statement on why the organs were not properly screened before the transplant or when it actually discovered that the donor had HIV.

The department has demanded that the hospital present a full report on the incident in three days.

Shih said the hospital had apologized to the patients and their families as well as briefed them on the situation. He added that to the best of his knowledge, the hospital had consistently conducted HIV-testing on organ donors.

“We don’t know at the moment what went wrong in this case, which has left five innocent organ recipients facing the risk of contracting AIDS,” Shih said.【相關報道】

臺大發生重大醫療疏失，除了讓五名器官受贈病患極可能感染艾滋病，包括臺大、成大兩家醫學中心，共有47名醫護人員也暴露在感染艾滋風險。換句話說，因爲臺大內部溝通出問題，連同病患及醫護人員，共有52人身陷艾滋恐懼之中。

據聯合晚報報道，事關重大，連遠在美國訪問的臺“衛生署長”邱文達都深表遺憾。“衛生署”公關室主任王哲超轉述，邱文達非常關心此事件的發展，已指示臺大醫院必須妥善照料這些器官受贈者，也要求“衛生署”內部檢討器捐移植流程，不要讓類似悲劇再度發生。

多年前，主導撰寫“臺大醫院器官捐贈小組標準作業程序”一書的臺大外科資深教授兼急重症加護病房主任和創傷醫學部主任柯文哲，上午面對記者採訪時，更是無奈，連聲嘆氣。

柯文哲指出，島內約有10家醫學中心執行器官移植手術，水準都不錯，但都各做各的，其中並無整合系統。這次臺大醫院將小錯變大錯，錯誤已經造成，希望島內相關醫院不要再各自爲政。

柯文哲說，“一個說講錯，一個說聽錯，不管怎樣，都是臺大的錯”。這項重大醫療疏失，讓臺大、成大共有47名醫護人員暴露在感染艾滋風險中。

如果“衛生署”給予最高懲處，臺大醫院器官移植小組恐將在一年內不得進行肝臟、肺臟、腎臟等移植手術。依照目前統計，受影響的病患恐多達1800人，這些在臺大等待器官移植的病患都必須得轉院。

臺大醫院發生有史以來最嚴重的致命錯誤，儘管院方坦承疏失，扛起責了任，但許多亟需器官捐贈來延續生命的病患，卻無辜受到牽連，影響就醫權益，這筆帳該向誰來算。

柯文哲無奈地說，他編撰器官捐贈移植手冊，想了一堆，也寫了一大堆，最後還是漏掉“艾滋感染”這一段。他曾經有想過，但最後還是沒寫進去。

柯文哲分析，造成這次大錯，就像是一個螺絲釘鬆了，以致於全部螺絲釘都掉了下來。他認爲，臺灣器官捐贈系統各自爲政的作法，應該要有所改革，不能再這樣下去。