Record number:
419
Adverse Occurrence type:
MPHO Type:
Alerting signals, symptoms, evidence of occurrence:
Twenty-eight of 29 bronchial washings (97%) taken from donors before retrieval grew at least one organism. The most common organisms identified were Staphylococcus and Enterobacter. In 12 of these cases (43%), similar organisms were isolated from the tracheobronchial tree of the recipients, and 6 of these recipients (21%) subsequently had invasive pulmonary infections as a result of the organism originally isolated in the donor.
Demonstration of imputability or root cause:
Similar organisms were isolated from the tracheobronchial tree of both donors and recipients, and 6 of these recipients (21%) subsequently had invasive pulmonary infections as a result of the organism originally isolated in the donor.
Keywords: