愛滋器捐風暴平息…器官移植條例 修法恐要再等

[MK]

http://tw.news.yahoo.com/%E6%84%9B%E6%B ... w--;_ylv=3


自由時報 – 2011年11月14日 下午12:41


台灣新生報 - 2011年11月14日 上午12:26
〔自由時報記者王昶閔／台北報導〕愛滋器官誤植風暴後，器官捐贈移植登錄中心角色與器官分配規則的位階備受爭議。然而，欲將器官登錄分配制度加以法制化的「人體器官移植條例修正草案」，原本修法在望，卻盛傳因風暴平息，且選舉將近，立委對修法興趣缺缺，社會對器捐制度改革期待恐再度落空。

人體器官移植條例修正草案主要在將器官登錄分配制度法制化，並針對器官仲介買賣祭出重罰手段，包括器官提供者、仲介者、醫療機構及醫師涉及器官仲介，最重可罰新台幣一百萬元，並可對違規醫療機構與醫師廢止其進行器官移植手術的許可。

該草案在二○○九年就送入立法院，竟一躺就是兩年，據透露，最近因新聞熱潮降低，選舉將近，立委對修法興趣缺缺。

但事實上，這起風暴帶給病患、家屬與醫護人員的創傷，至今難以抹去。一名參與愛滋器官移植的醫護人員雖已完成預防性投藥，近來卻動不動就感冒、口腔也容易潰瘍，似乎免疫力下降，同僚建議其抽血檢驗愛滋，再次追蹤。

台大醫院創傷醫學部主任柯文哲指出，現行器捐檢體的檢驗實驗室欠缺認證機制，政府對各醫院的流程與移植病患現況亦無監測機制，有些分明呼吸器已拿掉，卻還仍掛優先移植的1A級，「登錄中心資料的準確性有多少，大家心裡都有數」。

此外，器捐者的跨醫院病歷傳真分享，其適法性疑慮尚未解決。長庚醫院移植中心副主任江仰仁指出，衛生署直到八月底才發行政公函，要求器捐者檢驗資料要傳真至移植醫院與登錄中心，間接承認過去管理有疏失。但有醫事法律專家認為，此一作法與現行醫療法規恐有牴觸。

愛滋器官誤植事件的前端檢驗數據傳遞與登錄錯誤，責任正由衛生局與檢調單位釐清。由於根據錯誤數據做出器官分配排序的，則是由衛生署捐助成立登錄中心的電腦系統，擁有法學碩士學位的成大外科教授李伯璋分析，受害民眾應有請求國賠的空間。

[hitachi]

鄉民放大絕：
反正還有醫師要做!!
一定很好賺!!
為什麼要修法!!
等沒醫師做了再修吧!! (挖鼻孔)

[施肇榮]

鄉民放大絕：
反正還有醫師要做!!
一定很好賺!!
為什麼要修法!!
等沒醫師做了再修吧!! (挖鼻孔)

1.那就 TIME OUT ，病人等死

2.要不然就醫師多準備COCO被告吧

[李誠民]

還是不要輕易修器官移植法吧!
至少BMJ對台大"愛滋器官移植)烏龍事件是注意到了,對衛生署的處置只知處分(Blame)而不知blame並不能改善意外事件的發生與預防,目前僅是報導事件而已,當.......,台灣就只有灰頭塗臉了

以下是之前在本網站發言::

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?”---這在民主先進國家是不可思議的事,不本醫師良知與信仰,勇於揭發,彰顯真哩,醫師可以嗎?

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)

[hitachi]

如果blame 有用
開車就不用air bag, ABS, seat belt……

所謂意外，
就是人的意料之外，要用制度防呆……

台灣?? 就別修法吧!
再多死點人看會不會有進步 (挖鼻孔)

[李誠民]

因為"Blame"不就台大愛滋器官移植"烏龍"事件,不就平息了(?),那真相呢?以後意外事件就不會重演,?

柯大嘴巴不是也閉嘴了,套劇本網站的話---河蟹掉了!

不檢討 不再教育,來換取No Blame,

正面意義是No blame才會有真誠的檢討,才會透過教育避免意外再發生

[施肇榮]

因為"Blame"不就台大愛滋器官移植"烏龍"事件,不就平息了(?),那真相呢?以後意外事件就不會重演,?
柯大嘴巴不是也閉嘴了,套劇本網站的話---河蟹掉了!
不檢討 不再教育,來換取No Blame,
正面意義是No blame才會有真誠的檢討,才會透過教育避免意外再發生

醫師在刑法、民法、行政法、懲戒罰的淫威下

再多的檢討、教育只是在自證己罪，將來被他人拿來攻擊自己而已

現在狀況是連醫療刑責明確化，限縮在故意及重大過失都不可得的情形下

還在談廢棄民、刑事訴追的 NO BLAME

結論是民眾同意：真誠的檢討，可以透過教育避免意外再發生

醫師檢討、教育應該

只是醫師民事要照賠，刑事要照關 ，行政缺失要照罰，醫師要照樣懲戒!!