Shared Learning

Cautionary Tales

Cautionary Tales aims to provide insight into some of the clinical incidents reported to ODT. The aim is to share learning from incidents and so improve outcomes for patients.

 

DCD heart debriefs – learning and actions

A 12-month pilot of the UK wide DCD heart retrieval service was recently launched on the 7th September 2020. As part of that pilot it was agreed in the initial stages that the ODT Clinical Governance Team would facilitate debriefs for any donors where DCD heart retrieval proceeded.

The purpose of the debriefs are to include, wherever possible, the people that were involved in the donor process (SNODs, Hub Ops, Transplant Centres, NORS and IMT) to allow an opportunity to look at what went well and anything we can do to strengthen the process.

The attachments summarise the key learning and findings and the actions taken since the debriefs.

 

Additional shared learning

There are times when it is felt beneficial to share more detailed learning around specific cases due to the potential benefits to patient outcomes. On these occasions any relevant findings, learning or reports can be found below.