An important message from the MPSC on reporting Patient Safety events, DCD organ recovery pre-OR huddles, and other recommendations

Published on: Monday, April 15, 2024

For the benefit of the transplant community, the OPTN Board has authorized the OPTN Membership and Professional Standards Committee (MPSC) to disseminate learnings and effective practices observed during MPSC meetings and interactions with OPTN members. Updates will be provided by the MPSC after each of their in-person meetings.

The Organ Procurement and Transplantation Network (OPTN) Membership and Professional Standards Committee (MPSC) recently communicated to a large segment of OPTN members about several recommendations and opportunities for improvement in processes and protocols related to organ recovery and transplant:

Best practices when reporting Patient Safety events
DCD organ recovery pre-OR huddles
After action follow up and engagement with third party vendors

The MPSC is currently working on a number of initiatives which include:

The final implementation of the transplant program performance monitoring enhancement, in addition to regular performance reviews
OPO performance monitoring and the HRSA data collection directive
Discussing revisions to membership requirements in the OPTN Bylaws
Ongoing policy compliance and patient safety reviews
Monitoring completion and comprehensiveness of eGFR wait time modifications

These are areas of focus where the MPSC believes they can provide valuable information and tools for opportunities for improvement, support, and oversight.

The MPSC is an operating committee of the OPTN Board of Directors. In addition to monitoring for compliance with OPTN Final Rule, policies, and bylaws, the committee supports members through peer review and sharing of effective practices. Find the MPSC’s community updates and other materials on the MPSC resources page.

Best practices when reporting Patient Safety events

When reporting safety events to the OPTN Patient Safety Reporting Portal, it is best practice to inform other parties involved that an event is being reported. Open communication allows all members involved to understand the issue, work collectively to improve processes, and mitigate recurrences. Additionally, when possible, photographs should be included to verify and substantiate claims, especially related to organ anatomy or surgical damage. Reporting safety events is the responsibility of every member in the system and preemptive communication of a report should be well received. Working collaboratively as partners in the improvement process will also facilitate a smoother OPTN investigation process and allow for a more expeditious resolution.

The MPSC has also developed several patient safety resources for members that are available on the MPSC member resources page on the OPTN website. Resources include how to report events in the OPTN Patient Safety Reporting Portal and best practices for avoiding verification failures.

DCD organ recovery pre-OR huddles

Procurement teams are encouraged to have a pre-recovery huddle to ensure roles and responsibilities are clearly defined before procurement begins. As more teams become involved in procurement, there is more room for error. Instead of assuming everyone is on the same page, ensure that expectations, roles, and order of events are clearly discussed prior to incision. If confusion arises at any point in procurement, taking a time out is highly recommended to avoid a critical error that could lead to organ damage or non-utilization. Procurement teams are reminded to communicate early and often with the host OPO overseeing the process.

Some recurring errors the MPSC has seen in procurement include:

Bringing and using expired flush solution. All expiration dates should be checked prior to entering the OR and expired medications, solutions, additives, etc. should not be brought into the OR by any individual participating in the procurement.
Timing of flush, blood use, and order of team operations. Everyone participating in the procurement should be aware of the needs of other participants and the planned order of each step of procurement. Clear identification of who will be doing what, in what order, and how the timing of each action impacts the actions of the other teams is vital.
Inconsistent use of internal and external labels on pumps. Procurement teams are reminded to review OPTN Policy 16.3: Packaging and Labeling and consider what, if any, of their processes need to be modified to ensure compliance with labeling requirements. The inclusion of additional devices and pumps in transportation does not change organ labeling requirements.

After action follow up and engagement with third party vendors

Members are reminded that they are responsible for the actions of the third-party vendors (e.g., those providing services for organ procurement, offer screening, etc.) that they contract with. Members are encouraged to set clear expectations with vendors for after action review when patient safety events occur, including what documentation the vendor will need to provide to the member for root cause analyses, corrective action plans, and other relevant review processes. It is recommended that members take an active role in these after action reviews. When an MPSC inquiry and investigation occurs, members will continue to be held accountable for the actions of their vendors and will be expected to provide documentation between the member and vendor. As such, members should feel empowered to set high standards of review for their vendors and integrating after action follow up into their contract.

For questions or comments regarding this communication, please email MQFeedback@unos.org