OPTN
Proposal to Require Extra Vessels Disposition Reporting to the OPTN in Five Days of Transplant or Disposal
Sponsored by the Operations and Safety Committee (OSC)
Phillip C. Camp, Jr, MD – Chair
Jean Davis – Vice Chair
Spring 2012
OPTN
Importance of Extra Vessel Data Tracking spread of disease
2004 - Rabies transmission through extra vessel transplant
2009 – HCV transmission through extra vessel transplant
Care and Follow up of Recipients New clinical information related to donor disease
identified post transplant; and Communicate new information – can affect outcomes - care or treatment of recipients; can save lives
OPTN
Extra Vessels Data Collection Extra vessel data collection differs from solid organs
due to timing of use, storage, and possible disposal at a later time.
OPOs list in DonorNet extra vessels sent with each organ
Transplant centers report extra vessels used for transplant • at waiting list removal (with vessel donor ID) or later
using Vessel Use Report.• may also report extra vessels use or disposal via fax
or email to UNOS Data Quality.
OPTN
Extra Vessels Disposition Reporting Data
Cases Where Vessels Reported Recovered and Sent with Deceased Donor Kidney, Liver, Pancreas, or Intestine During 2008 - 2010
*Data as of June 17, 2011.
OPTN
Vessel Disposition Reported at Waiting List Removal or by Fax. Transplants 1/2011-11/2011:
Over 3,000 (11.8%) recipients have “vessels used?” equal to “unknown”. Over 400 (40.7%) PA or KP transplants had “vessel used?” equal to No.
WERE EXTRA VESSELS USED IN THE TRANSPLANT PROCEDURE:
Total (ALL)Unknown No Yes
N % N % N % NTransplanted organ
427 11.1 3,413 88.5 17 0.4 3,857Thoracic
Intestine5 4.0 44 35.5 75 60.5 124
Kidney1,630 10.6 13,709 88.9 74 0.5 15,413
Pancreas/KP170 16.9 410 40.7 428 42.5 1,008
Liver872 14.9 4,547 77.9 421 7.2 5,840
Total (ALL)3,104 11.8 22,123 84.3 1,015 3.9 26,242
OPTN
Patient Safety Planning Development Subcommittee
Review trends and patterns of safety events reported to the OPTN and disseminate information for process improvement:
• Quarterly Patient Safety Newsletter;• Enhancement to safety situation reporting data
points;• Encourage Best/Successful Practice reporting;• Quick Reference Guide to Reporting Safety
Events to the OPTN.
OPTN
ABO Verification Develop a matrix to document critical points in the
processes of ABO checks and verification
Assess current policy language to create symmetry and clarity were possible:• Separate determinations vs. separate occasions;• Prior to incision, prior to donation, prior to implant – are
these appropriate time measures for safe practice?• confirmation vs. verification
Develop standardized documentation tool for ABO verification
OPTN
Organ Tracking and Traceability
Assessing standardized coding system (ISBT 128)• Labeling• Barcoding• Tracking/Traceability
Feasibility study of coding system (ISBT 128)• Benefits and risks• Security of information• Cost savings or additions• Efficiencies gained? • Enhanced patient safety?
OPTN
Transportation Failures and Near Misses
Annual review of Organ Center data
Enhancement of data points being proposed to the Patient Safety electronic reporting system in UNetSM
Poster accepted for ATC on Organ Center data
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