BACKGROUND: Transplantation and, in particular, living donor liver transplantation (LDLT), involves complex systems and process of care that are particularly susceptible to medical errors and preventable complications. In order to capture safety issues during LDLT procedures, a proactive, web-based clinician safety debriefing tool was developed and implemented at four Adult-to Adult Living Donor Liver Transplant (A2ALL) hospitals. METHODS: All clinicians at four A2ALL centers who participated in LDLT procedures (Donor, Recipient) between Sept. 2012 and Oct. 2012 received a request to complete the web-based Safety Debriefing via email immediately after an LDLT surgery. The debriefing tool takes less than 3min to complete and provides clinicians with 24 prompts (e.g. “Access to Necessary Clinical Data”, “ABO Matching”) to elicit recollections of complications, near miss events and other safety issues that occurred. Reporters were identified, but answers were anonymous.

RESULTS: 85 LDLT surgeries were debriefed. Responses were provided by surgical staff (32%), nursing staff (30%), anesthesiology staff (20%), and others (18%) (Perfusionists, Techs, Radiology team, Observers, etc.). 542 safety issues were reported. The most common reported categories were related to equipment problems (15%), distractions (10%), inter-provider communication (8%), and timing of related procedures (6%).

CONCLUSIONS: Anonymous, short, online debriefings can successfully elicit rich information on the safety risk associated with LDLT surgery far beyond hospital wide reporting systems, which captured less than 5% of safety issues related to LDLT surgeries reported in the online debriefings. This is supporting evidence that to date safety risks associated with LDLT are poorly described and vastly underestimated. The proactive comprehensive safety risk assessment of LDLT is crucial in the quest to perform safety LDLT surgeries for donors and recipients.

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