Dear Colleagues,

You may have come across an article in Monday's Toronto Star about the illegal sale and acquisition of human tissue from a New Jersey cadaver tissue bank. There's concern that the tissue may not always have been obtained from safe sources. The District Attorney's Office in Brooklyn, N.Y. is launching an investigation against the company. More important, the article states that several Ontario hospitals, including Toronto Western, have used human tissue from this source.

As we know, situations like this arise from time to time in today's health care environment. As a health care organization committed to transparency and accountability, we take a series of steps whenever something like this comes to our attention. As soon as an issue is identified we pull together experts from the clinical care team, Central Processing Department, Infection Control, Quality of Care Committee, Public Affairs, Ethics and Patient Relations to assess the situation and provide recommendations to Senior Management.

In this particular case, UHN became aware of this issue last October after Health Canada issued a recall for the human tissue products from this company. We took immediate action by reviewing our patient records for the particular time period and procedure. After we completed our trace back, we concluded that only two patients here had received the products mentioned by Health Canada. The surgeon contacted the two patients directly to discuss what had happened and we offered additional support from an infectious disease expert who could discuss what tests might be appropriate for the patients involved.

I'd like to thank everyone who is involved with these assessments and with the actions that fall out of the assessments. Sometimes we can contact individuals and ensure that they are fully aware as was done in this case. In other circumstances, a public notification is in order when we feel that we cannot expect to contact all patients who may have been affected. And sometimes, when there is no reason to believe that anyone has been affected, the incident is recorded as a 'near miss' and we learn from the experience. This is all a part of developing a culture where patient safety is paramount and we learn much from the 'near misses' and change the way we deliver care as a result.


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