Operations and Safety Committee Spring 2014

 Sharing Patient Safety Data/Lessons Learned  Analysis of patient safety situation data reports  Working with MPSC to receive routine referrals on safety topics  Will provide member education through  Patient Safety Alert  Patient Safety News  Regional Meeting Updates  Instructional Events Ongoing Committee Initiatives

Complete field testing Application development Beta testing BOD Presentation Ongoing Committee Initiatives Mar 2014 May 2014Sept 2014Nov 2014  Electronic Tracking and Transport Project (ETT)

Living Donor Evaluation Safety Issue Policy 2013 PHS Guideline Overlooked test result may lead to: Preventable disease transmission Near-miss disease transmission Specifies required tests, evaluations, exclusions Does not address process of reviewing results/determining approvals Recommends HIV, HBV, and HCV testing “as close as possible to the date of the donor operation, but at least within the 28- day time period prior to surgery.”

Suggestions to minimize risk: Living Donor Evaluation Create Living Donor Evaluation Checklist Develop Selection Committee evaluation procedure Implement “final” review prior to surgery date Add serologies to hard- stop on surgery day Conduct double verification when reviewing labs Document, Document, Document!

 Jean Davis Committee Chair  Name Region # Representative  Susan Tlusty Committee Liaison Questions?