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Standardize the Patient Safety Contact and Reduce Duplicate Reporting

eye iconAt a glance

Current policy

Current policy requires each Organ Procurement Organization (OPO) and Transplant Hospital to identify a patient safety contact (PSC) to be available 24 hours a day, 7 days a week to receive, respond and communicate infectious disease results. The current, written protocols used by OPOs and Transplant Hospitals are inconsistent and lead to a single point of failure for reporting potential disease transmissions. The Disease Transmission Advisory Committee proposes a standard policy for reporting disease transmissions, including notification, follow-up, and the receipt and dissemination of information to ensure timely communication of potential disease transmissions. The Committee also proposes transplant programs are the only Organ Procurement and Transplantation Network (OPTN) member type responsible for reporting recipient illness to the OPTN to remove current, duplicate reporting requirements.

Supporting media

View presentation PDF link

Proposed changes

  • Patient Safety Contacts
    • Require OPOs and transplant programs list a secondary PSC
    • Require that PSCs work at the OPO or transplant program for which they are listed
    • Require PSCs to have a valid phone number and email address listed
    • Require transplant programs and OPOS to review their PSCs at least every six months to ensure contacts are up to date
  • Require use of a system enhancement in the OPTN Donor Data and Matching System to communicate and acknowledge post cross clamp results of donor derived potential disease transmissions
  • Eliminate the requirement for OPOs to report recipient illness to the OPTN Improving Patient Safety Portal

Anticipated impact

  • What it's expected to do
    • Ensure more accurate and timely reporting of notifications of potential disease transmission and related communication
    • Allow for more efficient communication of potential disease transmission through organ transplantation between OPOs and transplant programs and to the OPTN
    • Remove duplicate reporting to the OPTN by limiting official reporting of recipient illness to the OPTN to transplant programs only
  • What it won't do
    • Does not change the requirement that OPOs report recipient illness to other transplant programs with recipients from the same donor

Terms to know

  • Patient Safety Contact: The position at an OPO or Transplant Hospital responsible for (1) receiving relevant medical information that may affect or change transplant recipient care, (2) communicating information to the appropriate medical professional responsible for clinical care of the transplant recipient(s) at the transplant program as soon as possible, but no later than 24 hours after becoming aware of a potential disease transmission, and (3) facilitating communication about the current clinical status of any transplant recipient for whom the transplant center is informed of a concern for a possible or proven disease transmission related to the donor.
  • Organ Procurement Organization: An organization designated by the Centers for Medicare and Medicaid Services (CMS) and responsible for the procurement of organs for transplantation and the promotion of organ donation. OPOs serve as the vital link between the donor and recipient and are responsible for the identification of donors, and the retrieval, preservation and transportation of organs for transplantation.
  • OPTN Donor Data and Matching System: The component of the OPTN Computer System that focuses on the registration of deceased donors, organ matching, organ offers and placement.
  • Cross Clamp: When the flow of blood to a particular organ has been clamped off during an organ procurement.

Click here to search the OPTN glossary


Read the full proposal (PDF)

Provide feedback

eye iconComments

OPTN Organ Procurement Organization Committee | 02/20/2024

The OPTN Organ Procurement Organization (OPO) Committee thanks the Ad Hoc Disease Transmission Advisory for their work on this proposal and the opportunity to provide feedback. The Committee was strongly supportive of this proposal, particularly the proposal to require that the listed Patient Safety Contact must work at the OPO or transplant program for which they are listed. The Committee noted that third-party patient safety contacts may not always know what to do with potential disease transmission information, and thus create additional inefficiency in ensuring patient safety. There was also support for eliminating the requirement for OPOs to report recipient illness to the OPTN, particularly as this is both duplicative in consideration of transplant program requirements, and as the OPO is not responsible for the recipient’s care and follow-up.

Anonymous | 02/08/2024

Strongly agree with the key points mentioned and proposed changes. The amount of time spent entering information that had previously been submitted and waiting for responses from other centers can span over into the following day. Definitely agree with needing valid phone numbers (not pagers) and email addresses that are regularly monitored by an individual who understands the purpose of Patient Safety Contact and reporting. "Be available 24 hours a day" more often is met with voice messages of M-F office hours and no weekends/out of office for extended time with no delegate.
Having a secondary contact listed should alleviate this search/waiting task; however, suggest including if neither contact can be reached within the 24hrs, than notification goes directly to OPTN. This would be a built-in audit for OPTN of which centers need to update information/process implementation.
Thank you to the Committee for taking the time to acknowledge and propose changes to address common concerns and inefficiency.

Anonymous | 01/24/2024

The core patient's safety is the set priority in the medical industry. Without the measure of safety, the patients are exposed to infections, collateral contamination or death.