Record number:
569
Adverse Occurrence type:
MPHO Type:
Time to detection:
5 days
Alerting signals, symptoms, evidence of occurrence:
The first signal was the discovery of the transcription error at the testing laboratory where positive serology results were transmitted as negative. Three recipients with positive anti-HIV and HIV-RNA on day 5 after transplantation. The clinical course and treatment of one of the kidney recipients is published in detail.
Demonstration of imputability or root cause:
The donor was found to be HIV infected by serology and NAT testing, after the transplants were performed. The initial results had also been positive by serology but had been incorrectly transcribed. All organ recipients from the same donor were infected.
Imputability grade:
3 Definite/Certain/Proven
Keywords:
References:
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