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Transplant Adverse Event Policy and Thorough Analysis

This policy establishes protocols for reviewing, reporting, analyzing, and preventing adverse events in transplant centers. It includes a thorough analysis process to identify contributing factors and implement preventative actions.

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Transplant Adverse Event Policy and Thorough Analysis

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  1. Transplant Adverse Eventsand Thorough AnalysisUNOS Region 5 Collaborative Anne Gabriel, RN, BSN, CCTC, CPHQ, CMQ/OE March 15, 2017

  2. Transplant Adverse Event Policy A transplant center policy must address: Establishment and implementation of policies about how to review AEs Identification, reporting, analysis, and prevention of AEs Thorough analysis process of any adverse event How the analysis will be used to effect change 1

  3. What is a Transplant Adverse Event? Unanticipated death or serious injury Serious complications or death caused by living donation Transplantation of organs by mismatched blood types Unintended transmission of infectious disease to a recipient An event with potential to cause harm Source: 42 CFR 482.70 1

  4. What is a Transplant Adverse Event? An Event with Potential to Cause Harm • Operative complications • Event requiring higher level of care • Readmissions • Graft failure • Patient death • Medication Errors • Falls • Lab errors or delays • Infections • Returns to the OR • Rejections Source: 42 CFR 482.70 3

  5. Transplant Adverse Event/Patient Safety Process 4

  6. Thorough Analysis • Find the cause • Understand the cause • Find all potential issues • Review previous incidents to look for trends • To prevent future recurrences investigation • To identify areas for improvement 1

  7. Thorough Analysis • What happened? • When? • Where? • Who was involved? • What equipment or technology was involved • What policies, procedures or processes were involved? • Was it preventable? • Is there a risk of harm to others? 9

  8. Thorough Analysis - Contributing Factors 5

  9. Preventative Actions – Make a Plan Human factors – is more training needed? Environment – are safety measures in place? Equipment – is it old or malfunctioning Policies and procedures – are they followed or do they need updated? Organizational – does reporting between departments need to be reexamined? 1

  10. Follow Up Activities •Follow up and monitor actions – most often overlooked aspect of the process •Define the timeframes for when an action will be followed up to determine improvement •Sustain improvement to lead to improved patient outcomes 8

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