Background: The OPTN Operations & Safety Committee is charged with reviewing aggregated, de-identified safety situation data reported through the Improving Patient Safety (IPS) portal in UNet^SM. The Committee feels that accurate and timely reporting is essential to understanding major safety issues that face the transplant community and building a “culture of safety." Over the last year the Committee has worked on customizing this portal to increase ease of use as well as specificity of the data. The programming required to actuate these changes was approved by the OPTN Board of Directors. Once these changes go on line, they will be coupled with training efforts to improve ease of use and user understanding of the types of situations that should be reported.

Methods: The narrative associated with each event reported to the IPS between its inception (Mar 7, 2006) and Jan 31, 2012 was reviewed and categorized by a UNOS patient safety specialist and a biostatistician; some events fell into multiple categories. Excluded were reports not related to patient safety, potential disease transmissions without process errors, and living donor adverse events.

Results: Figure1 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 errors involved data entry, labeling, packaging, shipping, and communication.

Conclusions: There has been an increasing trend in reporting through the IPS but these numbers are still felt to represent only a small fraction of actual events. Slated improvements to the portal, coupled with increased awareness-building efforts within the transplant community, are expected to continue this trend and increase the ability to translate this data into improved systems that promote patient safety.

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