NHSBT adopt measures to avoid another error occurring
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 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 other 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;
• 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"
Responding to the publication of the review Public Health minister Anne Milton said
“Organ transplants save lives. However, the system relies on the generosity of people willing to donate.
“I would like to thank Sir Gordon for his work on producing this clear report. It is reassuring to hear that NHS Blood and Transplant handled the situation well once problems were identified.
“Organ Transplants are vital and I know that NHS Blood and Transplant will make sure such a situation never arises again.”
Notes for Editors
1. For Further enquiries please contact the DH Newsdesk on 0207 210 5221.
2. The full report can be found here:http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_120563
3. The organ donor register (ODR) is a computer database enabling people to make their wishes on organ donation known during their lives, potentially also saving their families from having to make decisions at a time of great distress.
4. NHS Blood and Transplant (NHSBT) manage the ODR, and several outside sources, including the Driver and Vehicle Licensing Agency (DVLA), feed into it (there is an option to volunteer for organ donation on the driving licence application form).
5. There are 17,087,646 registrants on the ODR and the error likely occurred in January 1999, potentially affecting 992,424 records.
6. Twenty-five families were actually affected by the error when consenting to organ donation by a deceased family member.
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