病人安全的正義與責任心間不責備態度(No Blame)的平衡點

[李誠民]

最近一期出刊的 BMJ(organ Taiwan transplant team blamed for HIV positive blunder :Jane Parry;BMJ 2011;343:doi:10.1136/bmj.d6523 (Published 10 October 2011))世界新聞專欄,報導台灣HIV-infected donor事件的文章;轉錄於下:

Taiwan’s Ministry of Health has blamed the transplant team and a hospital laboratory technician at the National Taiwan University Hospital for the transplantation of organs from an HIV positive donor in August this year.
The report does not name any single individual to take the blame.In a report released on 6 October, the team was excoriated for its failure to follow standard operating procedures. “We have described in detail how this incident happened, analysed the causes of the problem and uncovered some shortcomings. It’s our hope that all the hospitals can learn from this case and avoid making similar mistakes in the future,” Shih Chung-liang, director-general of the Taiwan Ministry of Health’s Bureau of Medical Affairs told the BMJ.
The National Taiwan University Hospital transplant team did not check the donor’s HIV status via computer records. Instead they relied on a conversation between the transplant coordinator and a laboratory technician who read out the HIV test result over the phone. The transplant coordinator misheard the English word “reactive” as “non-reactive.”

The man’s kidneys, a lung, and his liver were transplanted into four patients at the hospital. A fifth received the man’s heart at the National Cheng Kung University Hospital.

The director of the hospital’s department of traumatology and head of the transplant team Ko Wen-che resigned on 2 September, saying that he should be held responsible as he had written the transplant team guidelines and had formed and managed the hospital’s transplant team.
“I am prepared to come out and shoulder responsibility in order to protect the young medical technologist and the organ transplant coordinator who have already endured immense social pressure,” he told the BMJ.

He questioned the credibility of the report, however, as neither he nor anyone involved had been invited to offer an explanation or answer questions, and Department of Health officials had talked in the media about what his likely punishment would be.

“That is making a judgment before a trial,” he said. “What makes me angry is everybody is shifting the blame to someone else. Why do we always focus on getting someone punished rather than how we can make improvements, for example in our [medical] system?”

Five days after the incident, the patients began post-exposure prophylactic treatment but would need to wait until six months after they complete prophylaxis to know their HIV status.

It will be up to the Taipei City Government Department of Health to decide what consequences there may be for Dr Ko or other people involved in the incident. So far, the department has fined the hospital NT$150 000 (£3164, €3680, $5000) under the HIV Infection Control and Patient Rights Protection Act and NT$500 000 in accordance with the Medical Care Act.
這文章至少顯示兩點,讓國外醫學界不懂的地方,(個人觀點):
1.柯醫師所說的未審先判的荒謬性"He questioned the credibility of the report, however, as neither he nor anyone involved had been invited to offer an explanation or answer questions, and Department of Health officials had talked in the media about what his likely punishment would be"
2. 台北市衛生局的一罪兩罰

所以BML提前刊出台北醫學大學副校長--Yu-Chuan(Jack)Li的文章(十月十七日接受),也轉露於下:

Balancing "no blame" with justice and accountability in patient safety

Min-Huei Hsu, Director, Office for Science and Technology Development, Department of Health, Taiwan
Yu-Chuan (Jack) Li, Professor and Dean,College of Medical Science and Technology,Taipei Medical University, Taiwan
Office for Science and Technology Development, Department of Health, Taiwan



Taiwan first transplanted human organs in 1969 in a case that was also Asia's first kidney transplant. Modern transplant medicine in Taiwan has developed to global standards since then, and many transplant teams in Taiwan have worldwide reputations for quality and excellence.
Unfortunately, a patient safety event happened in Taiwan this August.[1] The family of a man decided to donate his organs after he fell into a coma, unaware that he was an HIV carrier. Medical technicians performing standard blood tests found that this patient was HIV-positive before his organs were harvested. But the message was wrongly relayed, and doctors carried out several transplant operations without this knowledge. The donor's heart, liver, lungs and two kidneys were transplanted to five patients on the same day. After the error was discovered, anti-HIV medications were prescribed for all organ recipients within 36 hours after the operations. Recent HIV test reports indicated negative results for all patients.

A root-cause analysis (RCA) revealed that the coordinator of the organ procurement organization keyed test results directly into the transplant center's database after receiving the result from a laboratory technician via telephone. A communication error led to "reactive" being misheard as "non-reactive." The information on the test result was not double-checked, as required by standard procedures. The head of the organ transplant team failed to verify the donor's HIV test result, and medical technicians failed to notify the doctors that the donor was HIV-positive.

Following the RCA finding, a forum on organ transplants was held where hundreds of experts were present and together advised six general directions for improvement include: 1) reforming Taiwan's organ donation and transplantation center by recruiting a full-time CEO and a medical director; 2) merging the various organ procurement systems of different hospitals into a single comprehensive department; 3) assuring fair and equitable distribution and optimum utilization of donated organs; 4)improving professionalism of the transplant teams; 5)establishing a national warning mechanism for HIV/AIDS-infected donors; 6)encouraging organ donations by all means. Taiwan's Department of Health will adopt the advice and proceed with timely reforms.

Most errors are committed by hard-working people trying to do the right thing. This event is a good example. The traditional focus on identifying who is at fault is a distraction. It is far more productive to identify error-prone situations and settings, and to implement systems that prevent errors. However, balancing "no blame" with justice and accountability in patient safety is a challenge for health officials.[2]
1.李副校長是引用NEJM2010的文章做標題,但他卻須很小心,因為宣稱台灣有好幾百名(?)移植專家開會,做出六點結論,是否誇大其公正性,也是是否會質疑的(台灣每年才有兩百例左右--去年170例--的腎移植,哪來好幾百位移植專家(?))
2.很少有醫學文章自誇自己國家的水準--"many transplant teams in Taiwan have worldwide reputations for quality and excellence",出非有他人文章佐證(也很少)

不過等後幾期BMJ應該有回應文章,對照台灣衛生主官官署的逞罰違手段的行為,不是很唪次嗎?(甚至是刑罰,不可笑嗎?)

參考文章:



1.Balancing “No Blame” with Accountability in Patient Safety

R.M. Wachter and P.J. Pronovost;NEJM,2009;361:1401-06

2.Balancing “No Blame” with Accountability in Patient Safety

N Engl J Med 2010; 362:275-276January 21, 2010---兩篇回應文章(to the editor)