OBJECTIVE/BACKGROUND:

According to the 2010 U.S. Office of the Inspector General’s Report, adverse events (AE) are common in the care of patients. In Living Donor Liver Transplantation (LDLT), given that living donors are healthy volunteers undergoing a major procedure purely for altruistic reasons, without any direct benefit for their own health, prevention of such events is particularly important, when caring for living donors and for the recipients to which they are donating. To inform critical targets for improvement to reduce AEs, we performed a review of medical records at four LDLT centers, to identify AEs as well as systems and process errors.

METHODOLOGY:

Paper and electronic medical records were collected from large transplant centers including documentation for the period of admission for transplant through discharge, plus any readmissions within 30 days. Systematic in depth medical record review was performed for 41 medical records (21 donor records and 20 recipient records) by a trained research nurse reviewer. All issues identified were reviewed by transplant surgeons to determine if an AE occurred. AEs were defined as an injury caused by medical management, rather than by the underlying disease.

RESULTS:

In the 41 reviewed records 727 issues were identified (313: donors, 414: recipients). The site distribution: A= 213, B=196, C= 94 and D= 224. Recipients had a mean of 21 issues (7-49) and donors had a mean of 14 (5-44). Twenty-eight percent (n=208) of issues were determined to be AEs: 42% (88) occurred in the care of donors, 58% (120) in the care of recipients. At least one AE occurred in the care of 100% of the donor and 100% of the recipients. The average number of AEs was 4.2 in donors and 6 in recipients. The most common types of AEs were related to Diagnostic (i.e. respiratory failure), Infections (i.e. UTI), Medications/Infusions (i.e. anaphylaxis), and Count Reconciliation leading to sequelae for the patient.

DISCUSSION:

This study demonstrates that AEs were common in LDLT. Given the results that AEs occurred in the care of 100% of donors and in the care of 100% of recipients it is critical to address these patients’ risks. These data can provide guidance to direct toward targets for improvement to reduce AEs and improve the overall safety and care outcomes of LDLT.

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