1. Operations and Safety Committee
Fall 2012 Public Comment Cycle

2. Recent Public Comment Proposals
Spring Extra vessels disposition reporting in 5 days
Final proposal – disposition reporting required every 7 calendar days
Electronic reporting available at implementation
The Operations and Safety Committee does not currently have a proposal out for public comment.
This spring, a proposal to report extra vessels disposition within 5 days of its use or disposal was put forth for public comment. The Public comment period ended on June 25th. Based on feedback, the committee has modified the proposal to require transplant centers to report extra vessels disposition every 7 calendar days. As part of this modification, committee staff have worked with UNOS IT to develop an electronic mechanism for reporting dispositions. Electronic reporting will replace the fax forms now required for reporting final disposition. Training will be provided to the membership before implementation.

3. Policy Implementation Dates
Extra vessels reporting proposal will be reviewed by the Board in November 2012
If approved, implemented on February 1, 2013
The committee met on September 13th to finalize the proposal based on public comment feedback. If the Board approves the proposal as submitted, the policy would go into effect on February 1, 2013.

4. Ongoing Committee Initiatives
ABO verification and documentation
Organ tracking and traceability
Patient safety data reviews
The Committee has several important initiatives that it continues to work on.
The OSC is reviewing current policy regarding checks and verification of donor and recipient blood type prior to donor organ recovery and implantation. The goal of their review is to develop a standardized documentation form for these processes that will include OPTN and CMS requirements.  
An Ad Hoc work group was created with representation from OPO, Transplant Administrators, Transplant Coordinators, and Operations and Safety committees. With this collaboration, the committee has identified at least 3 issues that may hinder compliance in this area:
#1 Misinterpretation of terminology with CMS regulation and OPTN policy
#2 Lack of consistency with current practice
#3 Lack of standardization of ABO processes
The committee is also conducting a feasibility study of the International Standard for Blood Transfusion code 128 (ISBT 128) which is a standard of identification, labeling, and information transfer. ISBT 128 could:
#1 Improve traceability by assigning a globally unique identifier for each organ type/product
#2 Improve safety and traceability by eliminating error-prone keyboard entry and transcription errors
#3 Improve efficiency by allowing scanned entry of organ information
#4 and has the potential for RFID tracking of organs in transport
HRSA is pursuing a project to address the vulnerability in the labeling, packaging and tracking system we currently use to identify, transport and monitor organs that move through the nation’s organ transplant system. Research, evaluation, and a proposal for revising the OPTN organ identification, packaging, labeling, and transport system is the desired outcome for this project. HRSA will keep the committee informed of their progress.
The committee also analyzes safety event data that centers and OPOs voluntarily report to the OPTN. This analysis helps them enhance patient and donor safety by identifying policy gaps and areas where the system could be improved. The committee has suggestions to improve the Patient Safety electronic reporting system in UNetSM. Their proposal recommends adding fields to the reporting system that would provide essential data needed for trending and analysis of safety events as well as rapid recognition of system breakdowns. It eliminates the need for centers to provide lengthy narratives and adds easy to use drop downs and radio buttons for reporting events.

5. Patient Safety in the News
You can find a newsletter highlighting important patient safety data and other topics on the UNOS member archive site. Newsletters from the Operations and Safety and the Disease Transmission Advisory Committees can be found here as well. You should bookmark this site and routinely review posts for updates on important safety topics. You’ll also receive a monthly e-newsletter that alerts you to new information that has been added to the site. If you don’t currently receive the e-newsletter you should send an to

6. New Committee Initiatives
Inactive waitlist transfers
Re-run match when donor serologies change
New Committee Initiatives –
The Committee is leading a joint working group to develop policy addressing how candidates would transfer from centers that have withdrawn their membership or indefinitely inactivated their program. That work group has recently been created and is beginning its discussions.
As well, the committee has been asked to participate in a joint working group that will address issues related to donor serologies that are not available at the time a match is run. This group is being led by the OPO committee.

7. Questions? Jean Davis, Chair Jean.davis@lifelinkfound.org
Theresa Daly, Vice Chair
Kimberly Taylor, Liaison