Audience: (Please share this notice with anyone in your organization who would benefit from it.)
- Transplant programs
- OPOs
- OPTN Primary and Alternate Representatives
- Histocompatibility labs (for awareness)
- The OPTN Membership and Professional Standards Committee
Implementation date
Jan.10, 2024
At-a-glance
Effective Jan.10, 2024, OPTN Policy 18.5: Reporting of Living Donor Events, has been updated to Policy 18.5: Reporting of Patient Safety Events and requires members to report certain patient safety events within 72 hours of becoming aware of the event. In addition, members are now required to report if a living donor is placed on the waiting list for any organ regardless of the organ that was donated.
What you need to do
Members should familiarize themselves with the patient safety events listed below that are required to be reported to the OPTN within 72 hours of becoming aware of the event.
Transplant programs are required to report:
- A transplant of the incorrect organ into an organ recipient occurs
- A transplant of an organ into the incorrect organ recipient occurs
- A donor organ is identified as incorrect during pre-transplant processes conducted according to either OPTN Policy 5.8.A: Pre-Transplant Verification Prior to Organ Receipt or OPTN Policy 5.8.B: Pre-Transplant Verification Upon Organ Receipt
- The potential transplant recipient is identified as incorrect during pre-transplant processes conducted according to either OPTN Policy 5.8.A: Pre-Transplant Verification Prior to Organ Receipt or OPTN Policy 5.8.B: Pre-Transplant Verification Upon Organ Receipt
- An organ was delivered to the incorrect transplant hospital and resulted in non-use of the organ
- The incorrect organ was delivered to the transplant hospital and resulted in non-use of the organ
- An ABO typing error or discrepancy is caught before or during pre-transplant processes conducted according to either OPTN Policy 5.8.A: Pre-Transplant Verification Prior to Organ Receipt or OPTN Policy 5.8.B: Pre-Transplant Verification Upon Organ Receipt
Organ procurement organizations (OPO) are required to report:
- An ABO typing error or discrepancy is caught after the OPO’s deceased donor blood type and subtype verification process, as outlined in OPTN Policy 2.6.C: Reporting of Deceased Donor Blood Type and Subtype, and after the OPO has executed a match run
The requirement for OPOs to report when “transplant hospital procurement staff leave the operating room without allowing the host OPO to package and label deceased donor organs and tissue typing specimens as required” has been moved from OPTN Policy 16.2 Packaging and Labeling Responsibilities to 18.5: Reporting of Living Donor Events.
Education and resources
An educational resource is available in UNOS Connect. Search “Reporting Safety Events” from the landing page to navigate to this resource.
Patient safety instructions in the OPTN Patient Safety Reporting Portal have been updated.
Questions
If you have questions relating to implementation, contact UNOS Customer Service at [email protected], or call 800-978-4334 from 8 a.m. to 7 p.m. ET.
For policy-related questions, contact [email protected].
The Organ Center is available 24 hours a day at 800-292-9537.
