Taiwan's health ministry expressed concern over the recent serious medical negligence saying that it may have tarnished the global reputation of the country's medical profession.
The donor scandal happened this summer involving five patients who received organs from an HIV positive donor.
The head of National Taiwan University Hospital's transplant team failed to properly check the donor's HIV test results, while lab technicians who knew of the results did not pass on the information, a ministry report said.
"This case was not just a shock for Taiwan society, but may also have impacted the global image of Taiwan medicine," said the report, released on the ministry's website late Thursday.
Of the five organ recipients, three have been discharged from hospital, and none has so far tested positive for HIV, according to local media.
The family of a 38-year-old man, surnamed Chiu, decided to donate his organs after he fell to his death in August, unaware that he was an HIV carrier.
Medical technicians performing standard blood tests found that Chiu was HIV positive before his liver, lungs and kidneys were harvested.
But the message was wrongly relayed and doctors were given the green light to carry out the operations. Health officials have called the cases "critical medical negligence".