Display options
Cite
Mathur AK, Stemper-Bartkus C, Engholdt K, et al. Identifying Patterns of Adverse Events of Solid Organ Transplantation Through Departmental Case Reviews. Mayo Clin Proc Innov Qual Outcomes. 2019;3(3):335-343doi: 10.1016/j.mayocpiqo.2019.04.007.
Mathur, A. K., Stemper-Bartkus, C., Engholdt, K., Thorp, A., Dosmann, M., Khamash, H., Reddy, K. S., Aqel, B., Moss, A., Chakkera, H., Steidley, D. E., Pajaro, O., Shah, S., Oakley, E. J., & Douglas, D. (2019). Identifying Patterns of Adverse Events of Solid Organ Transplantation Through Departmental Case Reviews. Mayo Clinic proceedings. Innovations, quality & outcomes, 3(3), 335-343. https://doi.org/10.1016/j.mayocpiqo.2019.04.007
Mathur, Amit K, et al. "Identifying Patterns of Adverse Events of Solid Organ Transplantation Through Departmental Case Reviews." Mayo Clinic proceedings. Innovations, quality & outcomes vol. 3,3 (2019): 335-343. doi: https://doi.org/10.1016/j.mayocpiqo.2019.04.007
Mathur AK, Stemper-Bartkus C, Engholdt K, Thorp A, Dosmann M, Khamash H, Reddy KS, Aqel B, Moss A, Chakkera H, Steidley DE, Pajaro O, Shah S, Oakley EJ, Douglas D. Identifying Patterns of Adverse Events of Solid Organ Transplantation Through Departmental Case Reviews. Mayo Clin Proc Innov Qual Outcomes. 2019 Jul 19;3(3):335-343. doi: 10.1016/j.mayocpiqo.2019.04.007. eCollection 2019 Sep. PMID: 31485572; PMCID: PMC6713855.
Copy Download .nbib Format: NLM
Share it on

Mayo Clin Proc Innov Qual Outcomes. 2019 Jul 19;3(3):335-343. doi: 10.1016/j.mayocpiqo.2019.04.007. eCollection 2019 Sep.

Identifying Patterns of Adverse Events of Solid Organ Transplantation Through Departmental Case Reviews.

Mayo Clinic proceedings. Innovations, quality & outcomes

Amit K Mathur, Cynthia Stemper-Bartkus, Kevin Engholdt, Andrea Thorp, Melissa Dosmann, Hasan Khamash, Kunam S Reddy, Bashar Aqel, Adyr Moss, Harini Chakkera, D Eric Steidley, Octavio Pajaro, Sadia Shah, Elizabeth J Oakley, David Douglas

Affiliations

  1. Transplant Surgery, Mayo Clinic Arizona, Phoenix.
  2. Transplant Center, Mayo Clinic Arizona, Phoenix.
  3. Risk Management and Patient Safety, Mayo Clinic Arizona, Phoenix.
  4. Nephrology, Mayo Clinic Arizona, Phoenix.
  5. Hepatology, Mayo Clinic Arizona, Phoenix.
  6. Cardiovascular Medicine, Mayo Clinic Arizona, Phoenix.
  7. Cardiothoracic Surgery, Mayo Clinic Arizona, Phoenix.
  8. Pulmonary Medicine, Mayo Clinic Arizona, Phoenix.

PMID: 31485572 PMCID: PMC6713855 DOI: 10.1016/j.mayocpiqo.2019.04.007

Abstract

The best approach to adverse-event review in solid organ transplantation is unknown. We initiated a departmental case review (DCR) method based on root-cause analysis methods in a high-volume multiorgan transplant center. We aimed to describe this process and its contributions to process improvement.

METHODS: Using our prospectively maintained transplant center quality portfolio, we performed a retrospective review of a 30-month period (October 26, 2015, to May 14, 2018) after DCR-process initiation at our center. We used univariate statistics to identify counts of adverse events, DCRs, death and graft-loss events, and quality improvement action-plan items identified during case review. We evaluated variation among organ groups in action-plan items, associated phase of transplant care, and quality improvement theme.

RESULTS: Over 30 months, we performed 1449 transplant and living donor procedures with a total of 45 deaths and 31 graft losses; 91 DCRs were performed (kidney transplant n=43; liver transplant n=24; pancreas transplant n=10; heart transplant n=6; lung transplant n=3; living donor n=5). Seventy-nine action-plan items were identified across improvement domains, including errors in clinical decision making, communication, compliance, documentation, selection, waitlist management, and administrative processes. Median time to review was 83 days and varied significantly by program. Median time to action-plan item completion was 9 weeks. Clinical decision making in the pretransplant phase was identified as an improvement opportunity in all programs.

CONCLUSIONS: DCRs provide a robust approach to transplant adverse-event review. Quality improvement targets and domains may vary based on adverse-event profiles.

Keywords: CMS, Centers for Medicare and Medicaid Services; DCR, Departmental Case Review; M&M, Morbidity and Mortality Conference; OPTN, Organ Procurement and Transplantation Network; QAPI, Quality Assurance and Performance Improvement

References

  1. BMJ Qual Saf. 2016 Dec;25(12):986-992 - PubMed
  2. J Surg Res. 2005 Nov;129(1):6-16 - PubMed
  3. BMJ Qual Saf. 2017 May;26(5):350-353 - PubMed
  4. BMJ Qual Saf. 2017 May;26(5):381-387 - PubMed
  5. Am J Surg. 2017 Nov;214(5):780-785 - PubMed
  6. Jt Comm J Qual Improv. 2000 Oct;26(10):563-75 - PubMed
  7. Acad Med. 2016 Oct;91(10):1330-1 - PubMed
  8. BMJ Qual Saf. 2017 May;26(5):417-422 - PubMed
  9. Soc Sci Med. 2006 Sep;63(5):1201-12 - PubMed
  10. Jt Comm J Qual Improv. 2002 Oct;28(10):531-45 - PubMed
  11. Fed Regist. 2007 Mar 30;72(61):15197-280 - PubMed
  12. Am J Med Qual. 2007 Jul-Aug;22(4):232-8 - PubMed
  13. Teach Learn Med. 2016 Oct-Dec;28(4):439-447 - PubMed
  14. Am J Surg. 1999 Feb;177(2):136-9 - PubMed
  15. Curr Opin Organ Transplant. 2013 Apr;18(2):216-21 - PubMed
  16. J Surg Res. 2012 Sep;177(1):7-13 - PubMed

Publication Types