Safety Issues in Living Donor Kidney Transplant Identified through a Proactive Web-based Transplant Safety Debriefing Tool

RESEARCH OBJECTIVE: The Northwestern University Transplant Outcomes Research Collaborative (NUTORC) developed a proactive web-based debriefing tool to elicit safety issues related to the processes and systems of care during each living donor kidney transplant (LDKT) from all clinicians and staff involved. The tool was developed by an interdisciplinary team of patient safety experts, transplant clinicians and staff. STUDY DESIGN: 170 safety debriefings were completed related to 63 LDKT's between April 2010 and October 2010 at Northwestern Memorial Hospital. All members of the healthcare team received an email with a link to the transplant safety debriefing tool, in order to obtain a 360 degree assessment of safety issues related to LDLT. The transplant safety debriefing tool gathers anonymous answers, takes 3-5 minutes to complete and is completed online. Both open-ended questions and specific prompts are used to solicit comments on all medical errors, adverse events, near misses, and safety related system or process issues encountered during the procedure, unrelated to surgical technique. POPULATION STUDIED: All members of the healthcare team (e.g., surgeons, anesthesiologists, nurses, technicians etc.) participating in each LDKT procedure. PRINCIPAL FINDINGS: Attending surgeons (27%), scrub (21%) and circulating (21%) nurses completed the highest number of transplant safety debriefings. However, other roles contributed significantly as well: anesthesia attendings (7%), physician assistants (6%), certified registered nurse anesthetists (5%), anesthesia fellows and residents (3%), and surgical fellows (3%). A total of 308 specific issues were reported representing the views of the entire clinical team. The most frequently cited safety issues include Equipment (e.g. missing or faulty instruments), Inter-provider Communication (e.g. miscommunication between surgeons and anesthesiologists), and Distractions (e.g. paging during surgery). While surgeons completed more total debriefings surveys, nurses and physician assistants (PA) reported a higher total number of safety issues. CONCLUSIONS: LDKT is procedure involving complex processes and systems of care with many opportunities for medical error and adverse events. Our results demonstrate a significant variation in the number of safety issues reported across clinician groups, which may reflect differences in the safety culture and awareness. Training and reassurance of anonymity might increase the number of issues reported. IMPLICATIONS FOR POLICY, DELIVERY, OR PRACTICE: Rigorous and proactive, rather than reactive identification of safety issues during LDKT procedures allows for the identification of potential problems before a medical error or an adverse event occurs, hence providing the opportunity for mitigation.