Enhanced Reporting System to Improve Transplant Safety

The UNetSM online patient safety reporting system is undergoing a makeover for the first time since it was launched in 2006. The number of incidents reported through the system has grown from 21 the first year to 119 in 2013. The redesigned site is expected to “go live” at the end of May, according to the press release issued by the Organ Procurement and Transplant Network (OPTN) and the Health Resources and Services Administration (HRSA). The enhancements to the system will capture more accurate and more specific information about all kinds of patient safety issues. Professionals, patients, and families are encouraged to report not only transplant delays or discarded organs, but also “near misses,” so that the OPTN can address recurring problems that have the potential to cause harm.

Organization of Safety Issues

The reporting system in the Patient Safety Portal will include high-level categories, such as Transportation and Labeling. Once a reporter chooses a category, a menu of relevant subcategories will appear, such as the type of transportation involved. Reporters also will be asked to describe the people and/or organs involved, what happened, and the effects of the event on the planned transplant. The issue might involve the donor, the candidate, the organ, extra vessels, or difficulty reading labels. The result might include a delayed transplant, a lost opportunity to recover an organ, or a discarded organ, among others.

Reviews and Confidentiality

Reporters are required to give contact information, but their identities are not shared with others involved in the reported incident. Rather, they are kept confidential under the peer medical review process. Patient Safety Analysts gather additional information as necessary and assess the incidents. Then aggregated data without identifying information are presented to the Operations and Safety Committee, which looks for trends and possible improvements. The committee then shares its findings with transplant professionals so that they may develop strategies to improve safety based on the types of errors reported.

Recent Findings

The most recent report found that the most common cause of safety issues was breakdown in communication; 23 percent of the situations involved communication breakdowns. Other common issues involved testing (16 percent), allocation and placement of organs (13 percent), process or procedure issues with the transplant (13 percent) and data entry (12 percent). Labeling and packaging or shipping each contributed to 10 percent of reported incidents.

More specifically, communication problems often included inaccurate or insufficient information about the donor or the organ or vessel. There were delays and miscommunications involving important information such as the high risk status of donor. Testing problems often involved a hemodilution or HLA discrepancy.

When and What to Report

Organ Procurement and Transplant network policy requires transplant professionals to report disease that may have been transmitted from donors, malignancies, and certain adverse events involving living donors. Other patient safety events may be reported voluntarily; reporting is encouraged in order to improve quality and safety. A guide to reporting is available and training on the use of the new portal will be available at the portal when it is launched.