Operations and Safety Committee Fall 2014. Recent Public Comment Proposals Proposal to Modify ABO Determination, Reporting, and Verification  Did not.

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Presentation transcript:

Operations and Safety Committee Fall 2014

Recent Public Comment Proposals Proposal to Modify ABO Determination, Reporting, and Verification  Did not pass at Board of Directors meeting in November 2014  Questions regarding recovery verification (deceased donor) and role of recovery surgeon  Will revise and send back out for public comment in January 2015

Recent Public Comment Proposals Proposal to Make Subtyping References Consistent:  Subtyping terminology references will be same style: CurrentProposedPolicy found to be non-A1 or non-A1B found to be blood type A, non- A 1 or blood type AB, non-A 1 B 2.6.B to a blood type A2 or A2B to a blood type A, non-A 1 or blood type AB, non-A 1 B 13.7.B donor to be non-A1 (negative for A1) or non- A1B (negative for A1B) donor to be blood type A, non- A 1 or blood type AB, non-A 1 B 14.4.A.i

 Continued review of safety situation reports  Report results available on OPTN website and Transplant Pro  Enhancements to the Improving Patient Safety Portal (Patient Safety Situations)  Will provide data on organs not recovered, increased cold ischemic time (CIT) and organ discards  Working with MPSC to receive education topic referrals routinely Develop Process for Review and Sharing of Safety Data

Overall Trends in Patient Safety Situation Reporting

Reporting by Category (2012 – Jun 2014)

Events related to Organ Not Tx’d (2012-Jun 2014) Event Frequency and Organ Not Tx’d High Frequency Increased Frequency Selected as Top Priority communication issue - delayed communication 9Yes communication issue - inaccurate/insufficient donor or organ/extra vessels information 8Yes recovery procedure/process issue - injury to organ or extra vessels 7Yes living donor issue - organ recovered but not transplanted 5Yes packaging/shipping issue - switched laterality - kidneys* 5Yes recovery procedure/process issue - poor donor management 5 Most common events reported with organ not transplanted

 Theresa Daly, MS, FNP Committee Chair  Name Region X Representative address  Susan Tlusty Committee Liaison Questions?