Committee shares lessons learned from reported safety situations

Published on: Monday, November 10, 2014

Since 2012, transplant professionals have been able to report patient safety situations to UNOS through the Improving Patient Safety portal on the UNet homepage. They can also report these type situations by emailing UNOS staff or calling the UNOS patient and member services line.

As part of its charge, the OPTN/UNOS Operations and Safety Committee (OSC) periodically reviews the safety event information that professionals submit so they can identify trends and patterns. Then, they share the information with centers and OPOs so that these organizations can consequently strengthen their own prevention strategies and quality improvement efforts.

Improvements were recently made to the existing portal so that transplant professionals could categorize the information they submitted. Of the 572 reports submitted between June 2012 and June 2014, the most common high-level categories involved issues related to communication, testing, and transplant procedures or processes. The most common subcategories involved delayed communications, inaccurate or insufficient donor information, and vessel sharing.

System improvements highlight reasons for organ discard

Enhancements to the system, made in May 2014, now allow the professional to indicate whether the patient safety event contributed to the organ not being recovered, to additional cold ischemic time, or to the organ being discarded.

The narrative comments accompanying these reports further indicated that 11% of the reports were associated with organs that were never transplanted because of the event they reported. Because of the reporting improvements, when committee members looked at events that resulted in an organ not being transplanted, the most frequent reasons stated were delayed communications and inaccurate or insufficient donor information.

Committee members also focused on cases where living donor organs were recovered but not transplanted and where packaging or labeling issues confused left and right organs.

An OSC Patient Safety Advisory Group, led by Dr. Michael Green, will further study these reports and determine how to best share these lessons learned with the larger transplant community.