Sponsored by the Operations and Safety Committee (OSC) Phillip C. Camp, Jr, MD – Chair

1. Proposal to Require Extra Vessels Disposition Reporting to the OPTN in Five Days of Transplant or Disposal Sponsored by the Operations and Safety Committee (OSC) Phillip C. Camp, Jr, MD – Chair Jean Davis – Vice Chair Spring 2012

2. Importance of Extra Vessel Data • Tracking spread of disease • 2004 - Rabies transmission through extra vessel transplant • 2009 – HCV transmission through extra vessel transplant • Care and Follow up of Recipients • New clinical information related to donor disease identified post transplant; and • Communicate new information – can affect outcomes - care or treatment of recipients; can save lives

3. Extra Vessels Data Collection • Extra vessel data collection differs from solid organs due to timing of use, storage, and possible disposal at a later time. • OPOs list in DonorNet extra vessels sent with each organ • Transplant centers report extra vessels used for transplant • at waiting list removal (with vessel donor ID) or later using Vessel Use Report. • may also report extra vessels use or disposal via fax or email to UNOS Data Quality.

4. Extra Vessels Disposition Reporting Data Cases Where Vessels Reported Recovered and Sent with Deceased Donor Kidney, Liver, Pancreas, or Intestine During 2008 - 2010 *Data as of June 17, 2011.

5. Vessel Disposition Reported at Waiting List Removal or by Fax. Transplants 1/2011-11/2011: • Over 3,000 (11.8%) recipients have “vessels used?” equal to “unknown”. • Over 400 (40.7%) PA or KP transplants had “vessel used?” equal to No.

6. Policy Proposal - 5.10.2 Vessel storage The Transplant Center must designate a person to monitor and maintain records, destroy, and notify the OPTN of outcome and/or use of vessels. This designated person must maintain information on all donor vessels including monitoring and maintaining all records relating to the use and management of donor vessels (e.g. subsequent positive serology testing, monitor inventory of stored vascular conduitsvessels). This person must monitor the refrigerator, ensure records are up to date and available with the conduits vessels, destroy the vessels when expired, and notify report the vessel’s use or disposal tothe OPTN within 5 daysof when the Transplant Center uses or disposes of the vessel of its use or disposal.

7. Operations and Safety Committee Activity Updates Spring 2012

8. Patient Safety Planning Development Subcommittee • Review trends and patterns of safety events reported to the OPTN and disseminate information for process improvement: • Quarterly Patient Safety Newsletter; • Enhancement to safety situation reporting data points; • Encourage Best/Successful Practice reporting; • Quick Reference Guide to Reporting Safety Events to the OPTN.

9. ABO Verification • Develop a matrix to document critical points in the processes of ABO checks and verification • Assess current policy language to create symmetry and clarity were possible: • Separate determinations vs. separate occasions; • Prior to incision, prior to donation, prior to implant – are these appropriate time measures for safe practice? • confirmation vs. verification • Develop standardized documentation tool for ABO verification

10. Organ Tracking and Traceability • Assessing standardized coding system (ISBT 128) • Labeling • Barcoding • Tracking/Traceability • Feasibility study of coding system (ISBT 128) • Benefits and risks • Security of information • Cost savings or additions • Efficiencies gained? • Enhanced patient safety?

11. Transportation Failures and Near Misses • Annual review of Organ Center data • Enhancement of data points being proposed to the Patient Safety electronic reporting system in UNetSM • Poster accepted for ATC on Organ Center data

12. Questions?