The Organ Procurement and Transplantation Network (OPTN) Membership and Professional Standards Committee (MPSC) recently communicated to a large segment of OPTN members about several recommendations and opportunities for improvement in processes and protocols related to organ recovery and transplant:
- Managing multiple kidneys
- Reducing risk by strengthening verification processes, using second verifiers to help ensure patient safety
These are areas of particular focus due to the risk they present to patient safety and public health, and the MPSC sees opportunities for improvement, support and oversight.
The MPSC is an operating committee of the OPTN Board of Directors. In addition to monitoring for compliance with OPTN Final Rule, policies, and bylaws, the committee supports members through peer review and sharing of effective practices. Find the MPSC’s community updates and other materials on the MPSC resources page.
Be vigilant when managing multiple kidneys
The MPSC strongly encourages members to pay particular attention and follow their organization’s established safety protocols when managing multiple kidneys to avoid transplanting the wrong organ. This serious safety event can occur when:
- Staff selects the wrong kidney and do not complete required verifications.
- Papers accompanying the organs are accidentally switched. Staff may complete the required verification steps using the correct paperwork, but the wrong organ.
- Kidney pump lids are accidentally switched. Staff may complete the required verification steps using the correct lid, but the wrong organ.
The MPSC encourages all programs to verify all information on the donor paperwork and both internal and external organ labels whenever possible
Reduce risk by building and strengthening verification processes, using second verifiers
If the incorrect patient is called in for transplant, it presents serious risk, since it allows all subsequent verifications to be completed against the correct donor information, and with recipient information that matches the candidate called in for transplant, without immediately realizing the person to whom the organ was allocated did not receive the transplant.
Contributing factors the MPSC has seen in these and other near misses and serious safety events include:
- New and/or additional staff in the OR, resulting in changes to verification processes.
- Variability in verification processes based on surgical team preferences.
- Though verification processes were consistent and staff could articulate the required steps, staff assumed someone else completed critical steps.
- Staff fatigue, often due to lack of resources and/or significant increases in volume.
The MPSC is working on more fully-detailed safety event case studies and will make this information available on the MPSC resources page as it develops.
To help ensure patient safety, the MPSC drove two verification enhancements in 2022 that are available to all programs:
- The match run results page now shows an informational warning for candidates who share the exact same first and last name with another candidate listed at the same transplant program.
- “Center Patient ID”, an optional field in Waitlist, allows your program to document a unique patient identifier, such as the patient’s MRN. This field is readily visible from the match list and is an additional way to verify patient identity.
To ensure programs are transplanting the correct patient, the MPSC encourages everyone to develop, implement, and strictly adhere to processes to verify the patients’ identity using the match run. The MPSC also encourages everyone provide training and educational resources on these and other critical processes to all staff involved in transplant, including contractors and traveling staff.
For questions or comments regarding this communication, please email [email protected]
