Vigilance and Surveillance EUSTITE Pilot Report

Title	Vigilance and Surveillance EUSTITE Pilot Report
Publication Type	Report
Year of Publication	2010
Authors	Sullivan S
Pagination	52
URL	http://www.notifylibrary.org/sites/default/files/EUSTITE%20V%26S%20Pilot%20Report_0.pdf
Notify Library Reference ID	1496

Related Incidents

61 - Pseudomonas aeruginosa - Cornea
96 - Hydrocephalus in a child born by donor sperm - Sperm
97 - Sperm from donor with ulcerative colitis was distributed and used - Sperm
98 - Sperm from donor with family history of congenital malignant hyperthermia was distributed and used - Sperm
119 - Mislabeling: Decontaminated Achilles tendons were distributed as 'irradiated' Achilles tendons - Tendon or Ligament
125 - Cultured skin autograft failure - Skin
129 - Tank containing amniotic membrane - liquid nitrogen ran out - all tissues and cells thawed and discarded. - Amniotic Membrane
130 - Loss of significant quantity of amniotic membrane due to improper monitoring/storage. - Amniotic Membrane
134 - Spongiose chips failure - Bone
135 - Cranium autograft failure - Bone
143 - Femoral Heads. Electrical power supply to storage freezer switched off by contractors. Some material disposed of. - Bone
165 - Tank containing bone - liquid nitrogen ran out - all tissues thawed and discarded. - Bone
166 - Massive bone graft packaging ruptured; discovered at hospital. - Bone
179 - Collection discontinued from matched apheresis stem cell donor due to diagnosis of leukemia in the donor - Apheresis
180 - Transcription error by collection staff listing an HCV reactive as non reactive - Apheresis
184 - DMSO toxicity - Marrow
344 - Cord Blood collected on unlicensed premises without appropriate agreements in place - lack of control over procurement - Cord Blood
345 - Cord Blood. Seven units of cord blood lost during transit to private cord blood bank because flight diverted and material lost for eight days in system by courier. Cells discarded upon receipt at TE. - Cord Blood
356 - PBSC procured in European country and transported to transplant centre in another MS. Due to adverse weather conditions plane (and cells) were delayed Patient failed to engraft. - Apheresis
357 - Poor bone marrow graft quality, low cell count post thaw - Marrow
358 - Positive microbiological control on the deswelling medium of the cornea (Staphylococcus haemolyticus) reported by the transplanting center - Cornea
359 - Problems in the temperature during transportation - Cornea
360 - Procurement of cornea without adequate consent. - Cornea
361 - Product related graft failure, due to poor quality - Marrow
363 - Respiratory insufficiency, hypertension post infusion - Marrow
375 - Bacterial infection/sepsis (Propionibacterium acnes) - Marrow
400 - Corneal Abscess - Cornea
612 - Enterococcus - Bone
622 - Pelviperitonitis in patient after implantation of embryos - Embryo
691 - Failure to engraft - Apheresis
699 - Cardiopulmonary arrest - Marrow
701 - Coma during infusion of autologous HSC - Marrow
702 - Cutaneous rash - Marrow
711 - Lymphoma found in donor by pathology after cornea had been transplanted. - Cornea
712 - Neurological complications - Marrow
714 - Gametes thawed and lost - Sperm
715 - PBSC accidently transported on dry ice instead of ice packs resulting in reduced cell viability - Apheresis
716 - Low cell count at thawing - Marrow
717 - Ovarian tissue damaged in transport - Ovarian tissue
719 - Cornea cut too thinly - Cornea
725 - Malarial antibody testing not performed althought indicated - Cornea
727 - Irreversible clotting of PBSC harvest procured for patient who had received immunoablative therapy - Apheresis
728 - Late fungal growth on last culture; corneas already transplanted. - Cornea
729 - Cornea storage media contamination - Cornea
732 - Poor quality cornea with folds and edema - Cornea
734 - Corneas lost due to transportation error - Cornea
735 - Incongruent donor test results - Cornea
759 - Citrate-induced hypocalcemia. - Apheresis
859 - Post donation septicemia (Staphylococcus epidermidis) - Marrow