Trends and Patterns in Reporting of Patient Safety Situations in Transplantation

• Published in: American journal of transplantation Vol. 15; no. 12; pp. 3123 - 3133
• Main Authors: Stewart, D. E., Tlusty, S. M., Taylor, K. H., Brown, R. S., Neil, H. N., Klassen, D. K., Davis, J. A., Daly, T. M., Camp, P. C., Doyle, A. M.
• Format: Journal Article
• Language: English
• Published: United States Elsevier Limited 01-12-2015
• Subjects: Communication; Data Collection; Databases, Factual; ethics and public policy; health services and outcomes research; Humans; organ procurement and allocation; Organ Transplantation; organ transplantation in general; Patient safety; Patient Safety - standards; Registries; Tissue and Organ Procurement - trends; Transplants & implants; United Network for Organ Sharing (UNOS); United States; United States; patient safety; ethics and public policy; organ transplantation in general; organ procurement and allocation; United Network for Organ Sharing (UNOS); health services and outcomes research
• ISSN: 1600-6135; 1600-6143
• DOI: 10.1111/ajt.13528

Analysis and dissemination of transplant patient safety data are essential to understanding key issues facing the transplant community and fostering a “culture of safety.” The Organ Procurement and Transplantation Network's (OPTN) Operations and Safety Committee de‐identified safety situations reported through several mechanisms, including the OPTN's online patient safety portal, through which the number of reported cases has risen sharply. From 2012 to 2013, 438 events were received through either the online portal or other reporting pathways, and about half were self‐reports. Communication breakdowns (22.8%) and testing issues (16.0%) were the most common types. Events included preventable errors that led to organ discard as well as near misses. Among events reported by Organ Procurement Organization (OPOs), half came from just 10 of the 58 institutions, while half of events reported by transplant centers came from just 21 of 250 institutions. Thirteen (23%) OPOs and 155 (62%) transplant centers reported no events, suggesting substantial underreporting of safety‐related errors to the national database. This is the first comprehensive, published report of the OPTN's safety efforts. Our goals are to raise awareness of safety data recently reported to the OPTN, encourage additional reporting, and spur systems improvements to mitigate future risk.
The authors summarize national patient safety‐related incidents reported to the OPTN and find a sharply increasing trend in reporting driven by a relatively small number of institutions, with events often involving communication breakdowns and leading to organ nonutilization. See the editorial from Axelrod on page 3021.