Purpose: Unbiased review of patient care in solid organ transplantation is difficult but essential for improving patient safety. In October 2013 we created a process by which select events were reviewed by a multidisciplinary team which then determined if standard of care (SOC) was met, and if a corrective action plan (CAP) needed to be implemented. We present results of 694 reviewed cases from our abdominal transplant program.

Methods: All cases presented for review between 10/2013 and 12/2015 were included. Cases came from adult and pediatric kidney, pancreas, liver, small bowel transplantation and hepatobiliary surgery. Cases were selected based on the following criteria: unexpected death, 1 year graft failure, operative complication, unplanned reoperation, medical complication, adverse event, near miss, reported medical event, 30 day readmission, donor disease transmission, and living organ donor adverse event. Members of the review committee include program leadership, director of quality, social worker, and physicians from the transplant department.

After review cases are graded as SOC met, SOC not met, or SOC met with room for improvement.

Results: We reviewed 694 cases since 10/2013. Adult liver service (liver transplant, pre and post, and hepatobiliary surgery) accounted for 426 cases and kidney/pancreas, small bowel and pediatric liver accounted for 198, 58 and 12 cases respectively.

Death within 1 year of transplant, other death (on the waiting list, while on service, or more than 1 year post-transplant), 30 day readmissions, unplanned reoperations, graft failure within one year, operative/procedural complications, medical complications, adverse events, near misses, reported medical events, donor disease transmissions, and living donor adverse events represent 5.2, 39.9, 28.1, 13.83, 1.59, 6.63, 3.03, 0.14, 0.29, 0.29, 0.72, and 0.29 percent of the cases, respectively.

SOC was met in 95.1% of adult liver cases; 91.9% of kidney cases; 94.8% of small bowel cases; 83.3% of pediatric liver cases. Cases where SOC was not met led to the creation and implementation of 43 CAPs.

Conclusions: We have created a process for multidisciplinary review of problematic clinical cases in abdominal transplantation. This has led to the discovery of patient safety problems and the creation of CAPs to prevent recurrence. We believe our approach can help guide other centers in quality and process improvement with benefits in both patient safety and long term clinical outcomes.

CITATION INFORMATION: Lerner S, Resta-Flarer M, Shapiro R, Florman S, Kim-Schluger L, Nair V. A Multidisciplinary Approach to Reviewing Patient Care in Abdominal Transplantation. Am J Transplant. 2016;16 (suppl 3).

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