A new way for professionals to report patient safety events

Published on: Sunday, April 27, 2014

The UNet(SM) online patient safety situation reporting system is getting its first big makeover at the end of May. Over the last few years, we have watched patient safety situation reporting grow from 21 reports to the Patient Safety Portal in 2006, to 119 in 2013. Learn how the online reporting system is changing and how it will benefit all transplant professionals and patients in the long run.

What will change?

System changes will allow transplant professionals to report more specifically and more accurately on the type of an event. You'll be able to choose from 10 high-level categories such as Labeling or Transportation. If you choose Transportation, for example, additional subcategories like Airline or Ground will display to help you more precisely define the type of transportation event that occurred. Other information including who or what was involved (donor organ/extra vessels, candidate, specific organs) and impacts from the situation (organ was not recovered, there was a delay in transplant, or the organ was discarded) will also be collected. While reporting is confidential, anyone reporting an event will be required to provide contact information. A pre-recorded training will be available in the UNet online help section to show you exactly which fields have changed and walk you through the process of reporting a patient safety situation.

What is a patient safety situation?

While we use the term safety, we collect reports on any event or process variance that could cause concerns from a transplantation, donation, or quality perspective. Of course, safety reporting is intended to include events involving an organ discard or patient harm. But the reporting portal is also intended to capture any event that causes concern, including a "near-miss." Reporting one near-miss may not seem important, however, if several institutions report the same type of situation, it may signal a pattern or area of potential system failure that the OPTN needs to address.

What do we do with the collected data?

Patient Safety Analysts with the Department of Evaluation and Quality follow up on safety situation reports. Information received, including the reporter's identity is kept confidential under the peer medical review process. Additional information may be requested to complete an assessment of the situation. The Operations and Safety Committee (OSC) reviews aggregate de-identified data from the system every six months. This review helps committee members identify trends and patterns that may indicate a need for system improvements. They then share their findings with transplant professionals like you so that you can become aware of potential safety situations and avoid them. We encourage transplant centers and OPOs to use these findings as a guide for identifying the kinds of errors that frequently occur. You may want to build quality assurance strategies around these areas. The most recent report showed that the most frequently reported events were related to communication (23%), testing (16%), organ allocation/placement (13%), transplant process/ procedure (13%) and data entry (12%) issues.

The OSC has used these reports in concrete ways. For example, when an OPO reported a Donor ID labeling error where the capital I was mistook for a capital L, UNOS switched fonts from Arial to Tahoma in UNet to ensure that patient identifiers could be easily read and interpreted. In another example, the OSC identified a pattern where extra vessels were being used in non-transplant procedures, which violates OPTN policy. This led to several educational efforts and a patient safety alert sent to thousands of transplant professionals. Data from health care literature estimates that only 5% to 15% of events are reported through safety systems. The OPTN continues to encourage organizations to first report, and then focus their prevention and quality improvement efforts on problem areas identified through those reports. Here's the latest report [Exit Disclaimer].

We're listening

We based our enhancements to the patient safety situation reporting portal on your feedback over the past seven years. Reporting in the improved system will help us better identify those errors which have the greatest impact (for example, loss of organ) and better categorize the types of events occurring. In turn, we will be better able to educate the transplant community about maximizing your patient safety efforts and identify potential areas for policy development and/or guidance.

A professional's guide to reporting

Transplant professionals are required by policy to report potential donor-derived disease transmissions and malignancies as well as certain types of adverse events involving living donors. Other types of patient safety situation reporting is voluntary but can lead to benefits and systems improvements for all.