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Adverse Occurrence type:
Rare; 0.47% for pancreas. For 12 consecutive months starting in January of 2014, 36 of 58 organ procurement organizations (OPO)s prospectively submitted quality data regarding organ damage (as reported by the transplanting surgeon and confirmed by the OPO medical director) seen on the procured organ. These 36 OPOs recovered 5401of the nation’s 8504 deceased donors for calendar year 2014. A total of 19043 organs procured were prospectively analyzed. Of this total, 59 organs sustained damage making them non-transplantable (0 intestines; 4 pancreatic; 5 lungs; 6 livers; 43 kidneys). The class 3 damage was spread over 22 (of 36) reporting OPO’s. While damage to the procured organ is rare with organ loss being approximately 0.3% of procured organs, loss of potential transplantable organs does occur during procurement.
Time to detection:
Immediately upon procurement.
Alerting signals, symptoms, evidence of occurrence:
Three levels of damage were agreed upon for the study and range from a level of “0” (no damage); level “1” (minimal damage sustained upon procurement requiring no intervention); level “2” (damage sustained upon procurement requiring some surgical repair but not rendering the allograft non-transplantable); and finally level “3” (damage sustained upon procurement rendering the allograft non-transplantable). Recovered pancreas= 855; Transplanted pancreas = 648; Type 1 damage = 7; Type 2 damage = 3; Type 3 damage = 4 [4/855 (0.47%)]
Demonstration of imputability or root cause:
A level of damage would be reported by the transplanting surgeon and reviewed and agreed upon by the medical director of the procuring OPO in consultation with the medical advisory board within that OPO (as deemed necessary by the individual medical director). Causes of Class 3 Injury for 4 Pancreas: Vascular injury (2); Traction injury to organ (2).
Deceased donor organ procurement injuries in the United States. Tim E Taber, Nikole A Neidlinger, et al. World J Transplant. Jun 24, 2016; 6(2): 423-428
Expert comments for publication:
Study is relevant and can lead to recognition of need for process improvements.