This ‘Signal’ is about problems for transplant teams with fatty, infected, incompatible or poor quality donated organs.
Extract from incident reported to the RLS:
“Renal transplant accepted… Kidney arrived completely surrounded by fat and muscle – nothing was recognisable. After dissection, a fatty tumour appeared on the upper pole, decision was taken to transplant anyway. After unclamping, there was a massive bleed from the tumour leading to urgent transplantectomy – kidney sent to the path lab – renal cell carcinoma… not fit for purpose.”
Following a trigger incident reported to the National Reporting and Learning Service (NRLS), all incident reports were searched and 11 substantive incidents relating to the condition of an organ for transplant or other errors were identified. These included examples of tumours on organs, `fatty’ organs, patient found to be infected (vCJD and hepatitis B) and trauma/laceration of organ as part of retrieval.
There were also incidents relating to systems failures with mis-matching of tissue typing and patient identification errors (patient details differing in local and national transplant registers).
The NRLS met with NHS Blood and Transplant in August 2009 to share these incidents. There was encouraging news on very recent changes where, for the first time, there will be a robust, secure and funded national system for organ retrieval, staffed by well-trained surgeons and other healthcare professionals. NHS Blood and Transplant is setting up a system for monitoring the quality of organs and this will be supplemented by a photographic assessment of livers that is currently being evaluated.
While these changes address many of our concerns, NHS Blood and Transplant strongly encourages staff to continue reporting all adverse events and any concerns about preventable harm to donated organs.
We would like to hear from you – please contact us with anonymised copies of local investigations or information about your initiatives to reduce risks in any of these areas.
Signals are notifications of key risks emerging from review of serious incidents reported and shared by the NRLS.
Relevant to: surgery
Short Survey on the value and effectiveness of Signals
This is a pilot project. To assess the value and effectiveness of Signals, we would be grateful if you and your staff could take a few minutes to answer a short survey. We would like to know if you have found Signals useful and how it could be developed further to suit your needs.