A recent editorial published in the Journal of the American Medical Association argues that more effective tracking mechanisms for transplanted tissue are needed to improve patient safety. Tissue banks provide 1.5 million tissue grafts each year. While most transplant recipients do not experience adverse effects, unintentional errors in procurement or processing can cause transplant recipient infection. In addition, intentional misconduct in the tissue procurement industry can increase safety risks for transplant recipients. Unfortunately, current tracking practices do not allow for rapid communication and product recall when these errors are discovered. The authors highlight two recent scandals involving the transplantation of illegally acquired and improperly processed tissues, explaining that because of inadequate tracking mechanisms, patient safety was compromised. Although the US Food and Drug Administration (FDA) requires tissues to be tracked from donor to the consignee or final destination, tracking within hospitals is not regulated. The authors suggest that the FDA should hold hospitals accountable for tracking tissues all the way to recipients. In addition, they propose that a standardized electronic tracking system, such as the ISBT-128 system used by the blood banking industry, be implemented for transplanted tissue.
Reference
1. DePaolo JS, Barbeau JM. Enhanced tracking of tissue for transplantation. JAMA 2013;309: 443-4.
