Trends and Patterns in Reporting of Patient Safety Situations in Transplantation.
Am J Transplant
; 15(12): 3123-33, 2015 Dec.
Article
em En
| MEDLINE
| ID: mdl-26560245
Analysis and dissemination of transplant patient safety data are essential to understanding key issues facing the transplant community and fostering a "culture of safety." The Organ Procurement and Transplantation Network's (OPTN) Operations and Safety Committee de-identified safety situations reported through several mechanisms, including the OPTN's online patient safety portal, through which the number of reported cases has risen sharply. From 2012 to 2013, 438 events were received through either the online portal or other reporting pathways, and about half were self-reports. Communication breakdowns (22.8%) and testing issues (16.0%) were the most common types. Events included preventable errors that led to organ discard as well as near misses. Among events reported by Organ Procurement Organization (OPOs), half came from just 10 of the 58 institutions, while half of events reported by transplant centers came from just 21 of 250 institutions. Thirteen (23%) OPOs and 155 (62%) transplant centers reported no events, suggesting substantial underreporting of safety-related errors to the national database. This is the first comprehensive, published report of the OPTN's safety efforts. Our goals are to raise awareness of safety data recently reported to the OPTN, encourage additional reporting, and spur systems improvements to mitigate future risk.
Palavras-chave
Texto completo:
1
Base de dados:
MEDLINE
Assunto principal:
Obtenção de Tecidos e Órgãos
/
Bases de Dados Factuais
/
Transplante de Órgãos
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Segurança do Paciente
Tipo de estudo:
Prognostic_studies
Limite:
Humans
País como assunto:
America do norte
Idioma:
En
Ano de publicação:
2015
Tipo de documento:
Article