Transcript UNOS/OPTN PPT template 04/2012

Proposal to Modify Sterile
Internal Vessels Label
Operations and Safety Committee
Spring 2015
The Problem

Sterile internal vessels label prone to error

Packaging and labeling of vessels #2 failure mode

Increase risk of accidental infectious disease transmission

Over 20 data fields marked using sterile pen in sterile field

Difficult to complete and read

Infectious disease results may not match hangtag label
Extra Vessels Labels
Sterile internal label
Hangtag poly-plastic label
Goal of the Proposal

Modify Policy 16.4.D (Internal Labeling of Vessels)

Reduce total data fields

Keep PHS Increased Risk field

Keep one critical and condensed data field for
infectious disease results:

These vessels are from a donor positive for
HIV, HBV, or HCV:
 YES  NO  PENDING
Picture of Proposed Modified Label
How the Proposal will Achieve its Goal

Reduce chances for error by reducing data fields

Keep most critical information

Direct back to source documents

Education on vessels repackaging for transplant
hospitals and OR staff
Supporting Evidence

Labeling and packaging of vessels: 2nd highest failure
mode

Nearly 75% of deceased donors include vessels
recovery

Vessels from HCV positive donors increased from
2.6% to 3.9%

Vessels from at-risk donors rose from 7.9% (“high risk”)
to 19.5% (”increased risk”)
Data periods: Totals: 2008-first half 2014
Era comparison 2008-10 to first half 2014
Supporting Evidence

Of 46,857 vessels recovered, 816 (1.7%) used in
secondary recipients

Of these, 63 (7.7%) were from high/increased risk

88 transplant hospitals used vessels in secondary
recipients and 25 did more than 10 cases

See proposal for safety situation reports, audit details,
disease transmissions
Data periods: Totals: 2008-first half 2014
Era comparison 2008-10 to first half 2014
What Members will Need to Do


OPOs will need to:
1.
Train staff to properly complete label
2.
Use revised sterile internal label starting
September 1, 2015
Transplant hospitals will need to:
1.
Familiarize staff to understand the new look
and results on revised sterile internal label
Specific Requests for Comment
Should the positive indication for HBV be for:
1. Any positive HBV testing result
OR
2. Solely for HBsAg positive results since storage of
these vessels is prohibited by policy
Questions?

Theresa Daly, MS, FNP
Committee Chair
[email protected]

Regional Rep Name
Region X Representative
email address

Susan Tlusty
Committee Liaison
[email protected]