All those involved in the donation, retrieval and transplantation pathway want to ensure that organs transplanted are as safe as possible for the recipient, and that donor family care is provided at a high standard. To achieve this we need people to feel able to report all incidents, confident that there will be no accusation of blame, and that incidents will be properly evaluated and investigated, and where appropriate, changes made to practice.
Every one shares the responsibility to make things better for all involved. Often people think that an incident is a ‘one off’ or ‘nothing to worry about’ and feel that there are no benefits to reporting or don’t want to ‘complain’ or ‘tell tails’. However what may seem a small thing or a one off may in fact be a wider issue. Near misses too should be reported to allow full review and, where appropriate, measures to be put into place to prevent recurrence and prevention of actual patient harm or donor family distress.
There is also a requirement for all UK establishments licensed under the Regulations to report Serious Adverse Events and Reactions (SAEARs) to NHSBT.
If this incident is urgent and may affect the quality and safety of an organ for transplantation or the treatment of recipients or potential recipients then please urgently call the ODT Duty Office 0117 975 7580 and inform them. This call should be followed by submitting via the shared learning portal.