1. Operations and Safety Committee Fall 2014

2. 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

3. 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

4.  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

5. Overall Trends in Patient Safety Situation Reporting

6. Reporting by Category (2012 – Jun 2014)

7. 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

8.  Theresa Daly, MS, FNP Committee Chair THD9003@NYP.ORG  Name Region X Representative Email address  Susan Tlusty Committee Liaison susan.tlusty@unos.org Questions?