Background: The OPTN Operations & Safety Committee is charged with reviewing aggregated, de-identified safety situation data reported through both the UNet Improving Patient Safety (IPS) portal and "other pathways", such as patient and member reports received via email or phone. The Committee uses these data to identify potential human or process errors that are reported frequently and/or have the potential to result in adverse events (e.g., organ discards), with the goal of improving patient safety and increasing transplant community awareness.

Methods: The narrative associated with each event reported to both the IPS and "other pathways" was reviewed and categorized by UNOS staff; some events fell into multiple categories. Excluded were reports not related to patient safety and potential disease transmissions without process errors. Figure 1 includes events reported to the IPS from March 2006 – June 2014. The year 2014 total was projected by doubling the number of events reported during the first half of 2014.

Results: Figure 1 reflects an overall increasing trend in reporting of safety situations.

Figure 2 divides the incidents into high-level categories based on the reported event description. A large number of reports involved issues with communication, testing, transplant and allocation processes, packaging/shipping, and labeling.

Conclusions: Although there is likely still a high degree of underreporting, the overall trend in reporting continues to increase. Recently implemented IPS improvements and ongoing educational efforts should result in both increased reporting and more thorough data to guide the development and progress of systems improvement efforts, such as electronic organ tracking.

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