Probabilistic risk assessment of accidental ABO-incompatible thoracic organ transplantation before and after 2003.
BACKGROUND
A widely reported ABO-mismatch accident in March of 2003 raised concerns about the reliability of the transplantation system. Because this type of failure is rare and significant, we performed a probabilistic risk assessment (PRA) of the donor-recipient matching processes for thoracic organ transplantation.


METHODS
A probabilistic risk assessment was performed.


RESULTS
The likelihood of accidental incompatible implantation was already low in 2003. The PRA model indicates that the likelihood of such an event was 1.38x10 per donated organ. This estimate correlates closely with the observed rate of these accidents. Based on this model, process changes put in place shortly after the accident reduced the probability to approximately 3.08x10 and changes put in place in October 2004 further reduced the probability to approximately 2.22x10 per organ donated.


CONCLUSIONS
The observed and predicted likelihoods of accidental incompatible thoracic organ transplantation are comparable. These likelihoods are several orders of magnitude smaller than other hazards associated with solid organ transplantation. The PRA model indicates that changes that followed the March 2003 accident further reduced the likelihood of accidental incompatible implantation by roughly two orders of magnitude. Quantitative estimates from PRA can be used to assess risks in healthcare and to gauge the impact of system changes on these risks.
Cook
Richard I
RI
Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL, USA. ri-cook@uchicago.edu
Wreathall
John
J
Smith
Alison
A
Cronin
David C
DC
Rivero
Oswaldo
O
Harland
Robert C
RC
Raman
Jai
J
Battles
James
J
Reason
James
J
D000017:ABO Blood-Group System; D001787:Blood Group Incompatibility / Q000453:epidemiology*; D006801:Humans; D018570:Risk Assessment; D013909:Thorax; D014181:Transplantation Immunology; D017211:Treatment Failure; D016896:Treatment Outcome
D000017:ABO Blood-Group System