The UNOS Operations and Safety Committee is charged with reviewing reported patient safety situations, identifying safety gaps, addressing high frequency and high impact events, and to explore ways to disseminate information to the transplant community regarding adverse events to heighten awareness of safety. Patient safety data is categorized into high level categories by UNOS staff. Shown here is data reported between 1/1/2017-6/30/, events can be categorized into more than one category and so total is greater than 100%. Of the 146 events reported, only 24 were classified as a non-issue or reported in error (16.4%). For data entry events, 13 were related to data entry issues in DonorNet, 4 of the 5 “other” events were related to Social Security number entry. Of the 21 testing related events, related events, the largest category (8) were hemodilution errors or discrepancies. Transplant procedure events were primarily (15/16) related to storage of vessels, there was one incident of use of vessels for non-transplant patient. All 5 living donor events were found to be unrelated to donation.

CITATION INFORMATION: Doyle A., Tlusty S., Urban R., Marvin M., Hollinger E., Marshman D., Green M. Trends in Safety Reporting to UNOS by Event Type Am J Transplant. 2017;17 (suppl 3).

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