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PSNet: Patient Safety Network
Journal Article
Commentary

Unintended transplantation of three organs from an HIV-positive donor: report of the analysis of an adverse event in a regional health care service in Italy.

Bellandi T, Albolino S, Tartaglia R, et al. Transplantation proceedings. 2010;42:2187-9.

This case study discusses errors that contributed to transplantation of infected organs and provides recommendations to improve test result communication and organizational safety culture.