Operations and Safety Committee Update Report to Board of Directors June , 2012 Phil Camp, Jr., MD - Chair

SM (N=232)

Patient Safety Reporting Institution Type 54.5% 38.2% 7.3% OPO's Transplant centers Labs

SM (N=301 situations)

Extra vessel data collection differs from solid organs:  Timing of use  Storage  Disposal at a later time OPOs indicate extra vessels sent in DonorNet ® Tx centers report extra vessels data:  Transplanted at waiting list removal or later using Vessel Use Report  Report disposal via fax or to Data Quality Extra Vessels Data Collection

Importance of Disposition Reporting #1 Patient Safety Protect against potential disease transmission transmission Reduce time for intervention when a Reduce time for intervention when a disease transmission has occurred disease transmission has occurred PATIENT SAFETY

Extra Vessels Reporting Data

Vessel Disposition Reported at Waiting List Removal or by Fax. Transplants 1/ /2011 : WERE EXTRA VESSELS USED IN THE TRANSPLANT PROCEDURE: Total (ALL) UnknownNoYes N%N%N%N Transplanted organ , ,857 Thoracic Intestine Kidney 1, , ,413 Pancreas/KP ,008 Liver , ,840 Total (ALL) 3, , , ,242

Disposition of Vessels Reported Sent From Proven/Probable 2011 DTAC Cases *Data as of April Disposition of Vessel Total Transplanted Into Same Recipient Transplanted Into Another Recipient Reported Destroyed Status Not Yet Reported N%N%N%N%N%

 91 programs - > 50% or >50 “unknowns”  Requested information on process of storage, disposition reporting, and suggested enhancements  54 respondents completed the survey  Timing of Reporting Vessel Usage:  At wait list removal  5 days  2-3 weeks  Several times a year  When log is full Outlier Programs Surveyed

 Policy report the vessel’s use or disposal to the OPTN within 5 days of when the Transplant Center uses or disposes of the vessel of its use or disposal. Extra Vessel Disposition Reporting Proposal

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.

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

Organ Tracking and Traceability  Assessing standardized coding system (ISBT 128)  Labeling  Barcoding  Tracking/Traceability  Feasibility of coding system (ISBT 128)  Benefits and risks  Security of information  Cost savings or additions  Efficiencies gained?  Enhanced patient safety?

Organ 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 UNet SM  Poster was accepted and presented at ATC on Organ Center data

Questions?