When you submit a living donor adverse event into the UNet Patient Safety System (PSS), the following review process is kicked off:
• Designated UNOS staff receive an email notification; UNOS staff quickly review report details and then communicate the information to designated UNOS and HRSA representatives
• if no patient safety concerns are evident, staff perform additional fact finding and write a report
• If patient safety concerns are identified, staff accelerate the fact-finding process and ensure that UNOS and HRSA representatives quickly review the results. Appropriate staff blind any details and findings from the review and send the report to the MPSC reviewers, who recommend an action for the full MPSC to consider
• the full MPSC reviews all living donor adverse event cases and all reviewer recommendations before making and approving a formal recommendation
• The full committee will take steps to proceed with any recommendation other than “no further action required.” For example, steps like a program interview, adverse action, referral to another committee for input, etc.
• After full MPSC approval of the action, all reported living donor adverse events are finally communicated to the Board of Directors
Up to now, members have had limited and controlled access to the reported information and any MPSC action taken, since it is considered peer medical review and confidential. We are exploring opportunities for members to learn from colleague experiences and are moving in the direction of making this information available in a format that doesn’t identify the program. Stay tuned.