Status:
Ready to upload
Record number:
1407
Adverse Occurrence type:
MPHO Type:
Time to detection:
N/A
Alerting signals, symptoms, evidence of occurrence:
Error without infection; exposure to hepatitis C from vessel conduit; discovered on review of serologic discordance between vessel donor and recipient
Demonstration of imputability or root cause:
Error without infection; exposure to hepatitis B from vessel conduit; discovered on review of serologic discordance between vessel donor and recipient
Groups audience:
Reference attachment:
Suggest references:
(CDC),(2011). "Potential transmission of viral hepatitis through use of stored blood vessels as conduits in organ transplantation--Pennsylvania, 2009." MMWR. Morbidity and mortality weekly report 60(6): 172-174.
Note:
Although hepatitis transmission did not occur in the two cases described in this report, the error of transplanting a vessel from a seropositive donor into a seronegative recipient was the same in these cases as it was in the case where transmission did occur; the error occurred despite appropriate labeling of vessel seropositivity. These are thus considered important “near miss” incidents in which transmission could have occurred despite appropriate safeguards being in place. Based on this investigation, CDC recommends that transplant centers discontinue the practice of storing vessels from donors with viral hepatitis markers. These markers include HBsAg, anti-HCV, or HBV or HCV detectable by nucleic acid tests. This discontinuation would apply to storage of vessels from donors seropositive or nucleic acid–positive, even if their storage was designated for use only with the original organ, because this practice still would not remove the potential for human error resulting in inadvertent use in a seronegative recipient. OPTN currently is considering a binding policy prohibiting storage of hepatitis-seropositive vessels at transplant centers.
Expert comments for publication:
Although hepatitis transmission did not occur in the two cases described in this report, the error of transplanting a vessel from a seropositive donor into a seronegative recipient was the same in these cases as it was in the case where transmission did occur; the error occurred despite appropriate labeling of vessel seropositivity. These are thus considered important “near miss” incidents in which transmission could have occurred despite appropriate safeguards being in place. Based on this investigation, CDC recommends that transplant centers discontinue the practice of storing vessels from donors with viral hepatitis markers. These markers include HBsAg, anti-HCV, or HBV or HCV detectable by nucleic acid tests. This discontinuation would apply to storage of vessels from donors seropositive or nucleic acid–positive, even if their storage was designated for use only with the original organ, because this practice still would not remove the potential for human error resulting in inadvertent use in a seronegative recipient. OPTN currently is considering a binding policy prohibiting storage of hepatitis-seropositive vessels at transplant centers.