Policy 12.8.5 states that an organ recovery center must report the following:
- all living donor organs recovered but not transplanted
- all living donor organs recovered but redirected and not transplanted into the intended recipient
You must report these cases through the Patient Safety System using the Living Donor Adverse Event portal within 72 hours of organ recovery
Since this policy was implemented 18 months ago, only two cases have been submitted through the Patient Safety System.
Case Study 1
A spot is discovered on a kidney during the living donor evaluation. The kidney is recovered and upon biopsy the spot turns out to be a renal carcinoma. The carcinoma was successfully excised and the kidney was then determined to be cancer-free so it is offered to the intended recipient. The original recipient rejects the kidney offer, so the kidney is offered to an appropriate candidate on the kidney waiting list who accepts it. The living donor is now cancer free and the waiting list candidate received a healthy kidney and was removed from the list.
Case Study 2
A spot is discovered on a kidney during the living donor evaluation. The kidney is recovered and upon biopsy once again the spot turns out to be a renal carcinoma. Surgeons are unable to successfully excise the total carcinoma so the kidney is discarded.
You are required by policy 12.8.5 to report both of these incidents. But beyond complying with policy, reporting these events through the patient safety system allows the transplant community to benefit from sharing best practices and knowledge that can result in transplant system improvements. If you have any questions about reporting cases such as these, please contact Dave Kappus at 804-782-4763.
