OPTN "Patient Safety News"

[Clark]

http://transplantpro.org/wp-content/uploads/Patient_Safety_News_09-2013.pdf

September 2013
In this Issue
The Operations and Safety Committee (OSC) continues to promote a
“culture of safety,” using what we have learned from past mistakes and
“near misses” to educate members about prevention and effective
practices. The committee reviews aggregate de-identified patient safety
data reports and other resources every six months to improve transplant
systems and processes. As a result of this work, you will read more about
the latest patient safety data and identification of extra vessels as an area
of concern. In addition, as part of promoting lessons learned, we will
highlight some effective member practices.
In other news, the committee continues its work to review ABO verification
processes and is conducting a failure modes and effects analysis (FMEA)
to identify system issues and gaps. Committee members also participated
in the electronic tracking and traceability (ETT) project, which developed
and pilot-tested an automated system to generate labels used in organ
procurement. Finally, OSC members are working with DTAC to review the
newly-released PHS guideline.
Articles
Making safety a part of your culture…………………………….1
Creating a ‘culture of safety’ – a priority for the OSC
Focus on documenting dialysis start-date……………………..2
The third most common policy violation
Potential Safety Events involving extra vessels………………3
Make sure you know all the rules
Transport and Tracking Project Reports Progress..…………4
Working to implement electronic solutions
New Public Health Service Guidelines……………………………5
What does this mean for you?