title: Trends and Patterns in Reporting of Patient Safety Situations in Transplantation.
abstract: 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.
authors.affiliation: Research Department, United Network for Organ Sharing, Richmond, VA.
authors.forename: D E
authors.initials: DE
authors.lastname: Stewart
authors.affiliation: Policy Department, United Network for Organ Sharing, Richmond, VA.
authors.forename: S M
authors.initials: SM
authors.lastname: Tlusty
authors.affiliation: Instructional Innovations Department, United Network for Organ Sharing, Richmond, VA.
authors.forename: K H
authors.initials: KH
authors.lastname: Taylor
authors.affiliation: Organ Center, United Network for Organ Sharing, Richmond, VA.
authors.forename: R S
authors.initials: RS
authors.lastname: Brown
authors.affiliation: Research Department, United Network for Organ Sharing, Richmond, VA.
authors.forename: H N
authors.initials: HN
authors.lastname: Neil
authors.affiliation: Chief Medical Officer, United Network for Organ Sharing, Richmond, VA.
authors.forename: D K
authors.initials: DK
authors.lastname: Klassen
authors.affiliation: LifeLink Foundation, Inc., Tampa, FL.
authors.forename: J A
authors.initials: JA
authors.lastname: Davis
authors.affiliation: New York Presbyterian Hospital, New York, NY.
authors.forename: T M
authors.initials: TM
authors.lastname: Daly
authors.affiliation: Brigham & Women's Hospital, Boston, MA.
authors.forename: P C
authors.initials: PC
authors.lastname: Camp
authors.affiliation: Department of Medicine, Drexel University College of Medicine, Philadelphia, PA.
authors.forename: A M
authors.initials: AM
authors.lastname: Doyle
mesh_terms: D003142:Communication; D003625:Data Collection; D016208:Databases, Factual; D006801:Humans; D016377:Organ Transplantation; D061214:Patient Safety / Q000592:standards*; D012042:Registries; D009927:Tissue and Organ Procurement / Q000639:trends*; D014481:United States
keywords: United Network for Organ Sharing (UNOS); ethics and public policy; health services and outcomes research; organ procurement and allocation; organ transplantation in general; patient safety