| Title | Notify exploring vigilance notification for organs, tissues and cells |
| Publication Type | Book |
| Year of Publication | 2011 |
| Authors | Notify Group |
| Number of Pages | 133 |
| Publisher | Editrice compositori |
| City | Bologna |
| Keywords | cell, organ, tissue, vigilance notification |
| URL | http://www.notifylibrary.org/sites/default/files/BOOK%20NOTIFY.pdf |
| Short Title | A global consultation organised by CNT with the co-sponsorship of WHO and the partecipation of the EU-funded SOHO V&S project. February 7-9, 2011 |
| Notify Library Reference ID | 1765 |
Notify exploring vigilance notification for organs, tissues and cells
Related Incidents
- 106 - Fractured graft in package, patient under anesthesia - Bone
- 107 - Vascular conduit cracks, requring repair in operating theatre - Heart valves
- 108 - Graft arrived at hospital thawed - Bone
- 109 - Tendon returned from hospital with no refrigeration, discarded - Tendon or Ligament
- 110 - Tendon graft mislabeled with improper expiration date and graft discarded at hospital - Tendon or Ligament
- 111 - Loss of shipped tissue which when located had thawed and thus unusable - Tendon or Ligament
- 112 - Irradiated tissue discarded due to discoloration and odor - Tendon or Ligament
- 113 - Tendon determined to be split upon opening package and thus not acceptable to the surgeon - Tendon or Ligament
- 114 - Inability to recover tissue during recall due to lack of hospital records - Tendon or Ligament
- 115 - Cryopreserved tendon discarded due to DMSO odor unrecognized by surgeon - Tendon or Ligament
- 116 - Tendon graft too small and too short - Tendon or Ligament
- 117 - Bone on bone-tendon-bone graft fragile and poor quality - Tendon or Ligament
- 121 - Valve Calcification, HLA incompatible - Heart valves
- 122 - Wrong sized heart valve package opened by mistake resulting in discard - Heart valves
- 123 - Heart valve determined to be unusable due to excess tissue attachments, discarded - Heart valves
- 124 - Heart valve mislabeled, delay in surgery, unneeded exposure to anesthetic - Heart valves
- 126 - Skin torn upon thawing and implanting, discarded - Skin
- 127 - Skin graft not measured properly and not acceptable resulting in discard by surgeon - Skin
- 128 - Distribution of cryopreserved skin without review of bacterial test results. - Skin
- 136 - Improper Sized Graft - Bone
- 144 - Graft lost in hospital - Bone
- 145 - Large osteochondral graft lost by FedEx - Bone
- 146 - Improper sizing of allograft resulting in surgeon discarding tissue - Bone
- 147 - Broken bottle of bone graft - Bone
- 148 - Transplant record returned with tissue not used but not with tissue. Upon investigation, the tissue had been used but no record made - Bone
- 149 - Tissue determined to be of unacceptable quality by surgeon and discarded - Bone
- 150 - Vacuum pack tested and loss of vacuum determined, graft discarded - Bone
- 151 - Graft fractured during shaping by surgeon and had to be discarded - Bone
- 152 - Inability to identify recipient of tissue during recall - Bone
- 153 - Only half as many bone chips in package as labeled, requiring delay to retrieve a second deposit - Bone
- 154 - Packaging contaminated during opening, tissue discarded - Bone
- 155 - Poor graft quality made surgery more difficult - Bone
- 156 - Inner package label and outer package label not matched, graft discarded - Bone
- 157 - Staples on package instructions penetrated inner package, graft discarded due to potential contamination. - Bone
- 158 - Fibula removed from package in the operating room but surgeon changed his mind about using it, discarded - Bone
- 160 - Bone considered too brittle at hospital - Bone
- 164 - Mislabeling of femur - Bone
- 168 - Tissue procured from wrong body - Heart valves
- 169 - Tissue procured from wrong body - Bone
- 170 - Tissue procured from wrong body - Tendon or Ligament
- 171 - Tissue procured from wrong body - Cornea
- 172 - Error in packaging, 2 menisci in one package, one was discarded - Meniscus
- 173 - Anatomic abnormality of meniscus graft, discarded at hospital - Meniscus
- 174 - Meniscus fracture - Meniscus
- 190 - Enterococcus faecalis - Osteochondral
- 348 - ABO mismatch - Kidney
- 349 - Exceeded pump time, organ discarded - Kidney
- 350 - Exceeded warm ischemia time, organ discarded - Kidney
- 354 - No recipient located and list exhausted, organ discarded - Kidney
- 355 - Organ traumatized during recovery, organ discarded - Kidney
- 362 - Recipient determined to be unsuitable for transplant in the operating room, organ discarded - Kidney
- 364 - Exeeded cold ischemia time, organ discarded - Kidney
- 365 - Ureteral damage, organ discarded - Kidney
- 366 - Vascular damage, organ discarded - Kidney
- 707 - Febrile reactions (transient) - Marrow
- 726 - Failed sterilisation of container lids - Cornea
- 731 - Organ packaging error - Kidney
- 1303 - Carbapanemase-producing Klebsiella pneumoniae - Kidney
- 1306 - Klebsiella pneumoniae, resistant to imipenem, meropenem - Kidney
- 1307 - Carbapanemase-producing Klebsiella pneumoniae - Liver
- 1378 - Creutzfeldt-Jakob disease - Bone
- 1433 - Human immunodeficiency virus (HIV) -
- 1536 - Malignancy - Multiple types or not specified
- 1535 - Infection (Viral and Parasitic) - Multiple types or not specified