Patient safety in living donor liver transplantation: Proactive safety debriefings

Research Objective: Several high profile transplantation patient safety events have been reported. Yet, there has been limited systematic research to describe the range of specific patient safety issues that occur in transplantation in order to direct effective preventive safety interventions and to improve transplantation outcomes. Active surveillance of safety issues and events can provide rate-based estimates of errors, adverse events, and near miss events.

Study Design: The NUTORC, Transplantation Safety Outcomes Group developed a proactive patient safety debriefing tool to capture safety issues and events from involved clinicians after each Living Donor Liver Transplantation (LDLT) procedure. The tool was developed by an interdisciplinary team of patient safety experts, and transplant clinicians and staff.

Population Studied: Safety debriefings were conducted between March and October, 2009 in the Division of Solid Organ Transplantation at Northwestern Memorial Hospital. All members of the healthcare team (e.g., surgeons, anesthesiologists, nurses, technicians etc.) involved in each LDLT transplantation procedure received an email with a link to the secure, web-based tool. The tool includes a consent which assures participant confidentiality and describes how the debriefings will be used to improve the transplantation process. The safety debriefing tool prompts participants to describe all errors, events, near misses, and safety related system or process issues encountered during the procedure. Open ended questions and prompts are used.

Principal Findings: A total of sixty-eight individual safety debriefing reports were collected following fifteen LDLT procedures. The most frequently reported patient safety issues included Teamwork/Communication (60% of procedures), Patient Anatomy (53%), Equipment Availability and Functioning (40%), Blood Products/Vessels (40%), IT/Data Access (33%), Coordination between Donor and Recipient Cases (33%), Staffing (33%), Physical Environment – OR Layout/Location (26%), Availability of Laboratory Results (26%) and Supply Availability (13%).

Conclusions: The online safety debriefing approach successfully maintains the anonymity of the reporters while gathering comprehensive information about the safety risks of the clinical activity. Each member of the healthcare team offers a unique perspective and this method allows for aggregate and individual-level assessment of safety issues. Additionally, by collecting safety debriefings data for each transplantation procedure can provide rate-based estimates of errors, adverse events, and near miss events.