A review into Queensland's Heart Valve Bank has found four people received tissue from a person who died of brain cancer because the approving doctors didn't have access to the donor's complete file.
The urgent investigation began earlier this year after it was revealed three babies under 12 months and an adult had received the matter.
It was finalised this week.
Queensland Health's chief health officer Sonya Bennett said the patients had been notified of the findings.
"The investigative team has reaffirmed with both Queensland Health and the affected families that the initial advice provided is correct - the risk of transmission of malignancy is extremely low to nil," she said.
News that makes sense
Your trusted source for staying up-to-date with the world around you. Get free daily news updates and analysis, straight to your inbox.
"This is reassuring news, but we have reiterated to the families that it should not have happened and want to apologise again."
The independent review found the reason for the blunder was because the bank's policy of making complete donor files available to reviewing doctors was not followed.
It also identified a series of failures by staff to adhere to quality assurance and clinical protocols, with a separate investigation under way into the conduct of some staff.
But it confirmed there had been no other incidents over the past 10 years.
Dr Bennett said the department would implement all of the recommendations in the report, including the merging of all tissue bank operations across the state.
Health Minister Steven Miles is expected on Thursday to formally announce the merge.
