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19/10/2010
Reassurances Offered To Organ Donors
A detailed review into how and why errors were made in recording the donation wishes of new would-be organ donors has been published today.
It praises NHS Blood and Transplant (NHSBT) for its sensitive handling of the incident, but concludes that errors could have been avoided if more robust procedures had been in place in 1999 when the error was made.
Sir Gordon Duff, who conducted the review, found that the error originated when faulty data conversion software was used by UK Transplant to upload data on donation wishes from the Driver and Vehicle Licensing Agency (DVLA) when it moved to a new computer system.
The review also outlines the remedial action taken by NHSBT and the actions taken to prevent a recurrence. Sir Gordon has concluded that once the error was identified and brought to the attention of NHS Blood and Transplant’s senior managers it was handled efficiently and sensitively.
With over 17 million registrants, there is a growing need for the register to become more interactive. Sir Gordon recommends that the longer-term solution is to create a more secure, interactive system with better data verification and cross reference functions and that NHSBT should take this forward as soon as resources allow.
His recommendations include: that NHS Blood and Transplant should continue to operate the current register but with a greater attention to sampling and cross referencing which will minimise the risk of this happening again; all external forms on which people are asked to agree to donate organs should collect information in a uniform way; the practice of writing to all registrants to thank them for agreeing to be an organ donor, and to give them the opportunity to report any errors should continue; and NHS Blood and Transplant should invite a third party experienced in secure database management to review its new controls.
Sir Gordon Duff said: "Organ transplantation is a much needed life-saving procedure.
"People who generously agree to donate their organs should be reassured that the error has been dealt with effectively and that steps have been taken to minimise the risk of it happening again.
"The current organ donor register, though still capable of being an effective tool, has some inherent constraints. I have therefore recommended that as soon as resources allow, NHS Blood and Transplant should design and commission a new register which will be better equipped to deal with the operational demands now placed on it"
(BMcN)
It praises NHS Blood and Transplant (NHSBT) for its sensitive handling of the incident, but concludes that errors could have been avoided if more robust procedures had been in place in 1999 when the error was made.
Sir Gordon Duff, who conducted the review, found that the error originated when faulty data conversion software was used by UK Transplant to upload data on donation wishes from the Driver and Vehicle Licensing Agency (DVLA) when it moved to a new computer system.
The review also outlines the remedial action taken by NHSBT and the actions taken to prevent a recurrence. Sir Gordon has concluded that once the error was identified and brought to the attention of NHS Blood and Transplant’s senior managers it was handled efficiently and sensitively.
With over 17 million registrants, there is a growing need for the register to become more interactive. Sir Gordon recommends that the longer-term solution is to create a more secure, interactive system with better data verification and cross reference functions and that NHSBT should take this forward as soon as resources allow.
His recommendations include: that NHS Blood and Transplant should continue to operate the current register but with a greater attention to sampling and cross referencing which will minimise the risk of this happening again; all external forms on which people are asked to agree to donate organs should collect information in a uniform way; the practice of writing to all registrants to thank them for agreeing to be an organ donor, and to give them the opportunity to report any errors should continue; and NHS Blood and Transplant should invite a third party experienced in secure database management to review its new controls.
Sir Gordon Duff said: "Organ transplantation is a much needed life-saving procedure.
"People who generously agree to donate their organs should be reassured that the error has been dealt with effectively and that steps have been taken to minimise the risk of it happening again.
"The current organ donor register, though still capable of being an effective tool, has some inherent constraints. I have therefore recommended that as soon as resources allow, NHS Blood and Transplant should design and commission a new register which will be better equipped to deal with the operational demands now placed on it"
(BMcN)
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