Communication gaps associated with donor-derived infections

R. Miller, S. Covington, S. Taranto, R. Carrico, A. Ehsan, B. Friedman, M. Green, M. G. Ison, D. Kaul, B. Kubak, D. J. Lebovitz, G. M. Lyon, M. A. Nalesnik, T. L. Pruett, L. Teperman, B. Vasudev, E. Blumberg

Research output: Contribution to journalArticle

16 Citations (Scopus)

Abstract

The detection and management of potential donor-derived infections is challenging, in part due to the complexity of communications between diverse labs, organ procurement organizations (OPOs), and recipient transplant centers. We sought to determine if communication delays or errors occur in the reporting and management of donor-derived infections and if these are associated with preventable adverse events in recipients. All reported potential donor-derived transmission events reviewed by the Organ Procurement and Transplantation Network Ad Hoc Disease Transmission Advisory Committee from January 2008 to June 2010 were evaluated for communication gaps between the donor center, OPO and transplant centers. The impact on recipient outcomes was then determined. Fifty-six infection events (IEs; involving 168 recipients) were evaluated. Eighteen IEs (48 recipients) were associated with communication gaps, of which 12 resulted in adverse effects in 69% of recipients (20/29), including six deaths. When IEs and test results were reported without delay, appropriate interventions were taken, subsequently minimizing or averting recipient infection (23 IEs, 72 recipients). Communication gaps in reported IEs are frequent, occur at multiple levels in the communication process, and contribute to adverse outcomes among affected transplant recipients. Conversely, effective communication minimized or averted infection in transplant recipients. This analysis of potential donor-derived infection transmission events reported to the Organ Procurement and Transplantation Network demonstrates that delays and errors in communication are frequent, occur at multiple levels in the communication process, and contribute to adverse outcomes among affected transplant recipients.

Original languageEnglish (US)
Pages (from-to)259-264
Number of pages6
JournalAmerican Journal of Transplantation
Volume15
Issue number1
DOIs
StatePublished - Jan 1 2015

Fingerprint

Communication
Tissue Donors
Tissue and Organ Procurement
Infection
Organ Transplantation
Organizations
Infectious Disease Transmission
Advisory Committees
Transplants
Transplant Recipients

Cite this

Miller, R., Covington, S., Taranto, S., Carrico, R., Ehsan, A., Friedman, B., ... Blumberg, E. (2015). Communication gaps associated with donor-derived infections. American Journal of Transplantation, 15(1), 259-264. https://doi.org/10.1111/ajt.12978

Communication gaps associated with donor-derived infections. / Miller, R.; Covington, S.; Taranto, S.; Carrico, R.; Ehsan, A.; Friedman, B.; Green, M.; Ison, M. G.; Kaul, D.; Kubak, B.; Lebovitz, D. J.; Lyon, G. M.; Nalesnik, M. A.; Pruett, T. L.; Teperman, L.; Vasudev, B.; Blumberg, E.

In: American Journal of Transplantation, Vol. 15, No. 1, 01.01.2015, p. 259-264.

Research output: Contribution to journalArticle

Miller, R, Covington, S, Taranto, S, Carrico, R, Ehsan, A, Friedman, B, Green, M, Ison, MG, Kaul, D, Kubak, B, Lebovitz, DJ, Lyon, GM, Nalesnik, MA, Pruett, TL, Teperman, L, Vasudev, B & Blumberg, E 2015, 'Communication gaps associated with donor-derived infections', American Journal of Transplantation, vol. 15, no. 1, pp. 259-264. https://doi.org/10.1111/ajt.12978
Miller R, Covington S, Taranto S, Carrico R, Ehsan A, Friedman B et al. Communication gaps associated with donor-derived infections. American Journal of Transplantation. 2015 Jan 1;15(1):259-264. https://doi.org/10.1111/ajt.12978
Miller, R. ; Covington, S. ; Taranto, S. ; Carrico, R. ; Ehsan, A. ; Friedman, B. ; Green, M. ; Ison, M. G. ; Kaul, D. ; Kubak, B. ; Lebovitz, D. J. ; Lyon, G. M. ; Nalesnik, M. A. ; Pruett, T. L. ; Teperman, L. ; Vasudev, B. ; Blumberg, E. / Communication gaps associated with donor-derived infections. In: American Journal of Transplantation. 2015 ; Vol. 15, No. 1. pp. 259-264.
@article{a532afed8c764db8ba9fcd6f7b22e2c1,
title = "Communication gaps associated with donor-derived infections",
abstract = "The detection and management of potential donor-derived infections is challenging, in part due to the complexity of communications between diverse labs, organ procurement organizations (OPOs), and recipient transplant centers. We sought to determine if communication delays or errors occur in the reporting and management of donor-derived infections and if these are associated with preventable adverse events in recipients. All reported potential donor-derived transmission events reviewed by the Organ Procurement and Transplantation Network Ad Hoc Disease Transmission Advisory Committee from January 2008 to June 2010 were evaluated for communication gaps between the donor center, OPO and transplant centers. The impact on recipient outcomes was then determined. Fifty-six infection events (IEs; involving 168 recipients) were evaluated. Eighteen IEs (48 recipients) were associated with communication gaps, of which 12 resulted in adverse effects in 69{\%} of recipients (20/29), including six deaths. When IEs and test results were reported without delay, appropriate interventions were taken, subsequently minimizing or averting recipient infection (23 IEs, 72 recipients). Communication gaps in reported IEs are frequent, occur at multiple levels in the communication process, and contribute to adverse outcomes among affected transplant recipients. Conversely, effective communication minimized or averted infection in transplant recipients. This analysis of potential donor-derived infection transmission events reported to the Organ Procurement and Transplantation Network demonstrates that delays and errors in communication are frequent, occur at multiple levels in the communication process, and contribute to adverse outcomes among affected transplant recipients.",
author = "R. Miller and S. Covington and S. Taranto and R. Carrico and A. Ehsan and B. Friedman and M. Green and Ison, {M. G.} and D. Kaul and B. Kubak and Lebovitz, {D. J.} and Lyon, {G. M.} and Nalesnik, {M. A.} and Pruett, {T. L.} and L. Teperman and B. Vasudev and E. Blumberg",
year = "2015",
month = "1",
day = "1",
doi = "10.1111/ajt.12978",
language = "English (US)",
volume = "15",
pages = "259--264",
journal = "American Journal of Transplantation",
issn = "1600-6135",
publisher = "Wiley-Blackwell",
number = "1",

}

TY - JOUR

T1 - Communication gaps associated with donor-derived infections

AU - Miller, R.

AU - Covington, S.

AU - Taranto, S.

AU - Carrico, R.

AU - Ehsan, A.

AU - Friedman, B.

AU - Green, M.

AU - Ison, M. G.

AU - Kaul, D.

AU - Kubak, B.

AU - Lebovitz, D. J.

AU - Lyon, G. M.

AU - Nalesnik, M. A.

AU - Pruett, T. L.

AU - Teperman, L.

AU - Vasudev, B.

AU - Blumberg, E.

PY - 2015/1/1

Y1 - 2015/1/1

N2 - The detection and management of potential donor-derived infections is challenging, in part due to the complexity of communications between diverse labs, organ procurement organizations (OPOs), and recipient transplant centers. We sought to determine if communication delays or errors occur in the reporting and management of donor-derived infections and if these are associated with preventable adverse events in recipients. All reported potential donor-derived transmission events reviewed by the Organ Procurement and Transplantation Network Ad Hoc Disease Transmission Advisory Committee from January 2008 to June 2010 were evaluated for communication gaps between the donor center, OPO and transplant centers. The impact on recipient outcomes was then determined. Fifty-six infection events (IEs; involving 168 recipients) were evaluated. Eighteen IEs (48 recipients) were associated with communication gaps, of which 12 resulted in adverse effects in 69% of recipients (20/29), including six deaths. When IEs and test results were reported without delay, appropriate interventions were taken, subsequently minimizing or averting recipient infection (23 IEs, 72 recipients). Communication gaps in reported IEs are frequent, occur at multiple levels in the communication process, and contribute to adverse outcomes among affected transplant recipients. Conversely, effective communication minimized or averted infection in transplant recipients. This analysis of potential donor-derived infection transmission events reported to the Organ Procurement and Transplantation Network demonstrates that delays and errors in communication are frequent, occur at multiple levels in the communication process, and contribute to adverse outcomes among affected transplant recipients.

AB - The detection and management of potential donor-derived infections is challenging, in part due to the complexity of communications between diverse labs, organ procurement organizations (OPOs), and recipient transplant centers. We sought to determine if communication delays or errors occur in the reporting and management of donor-derived infections and if these are associated with preventable adverse events in recipients. All reported potential donor-derived transmission events reviewed by the Organ Procurement and Transplantation Network Ad Hoc Disease Transmission Advisory Committee from January 2008 to June 2010 were evaluated for communication gaps between the donor center, OPO and transplant centers. The impact on recipient outcomes was then determined. Fifty-six infection events (IEs; involving 168 recipients) were evaluated. Eighteen IEs (48 recipients) were associated with communication gaps, of which 12 resulted in adverse effects in 69% of recipients (20/29), including six deaths. When IEs and test results were reported without delay, appropriate interventions were taken, subsequently minimizing or averting recipient infection (23 IEs, 72 recipients). Communication gaps in reported IEs are frequent, occur at multiple levels in the communication process, and contribute to adverse outcomes among affected transplant recipients. Conversely, effective communication minimized or averted infection in transplant recipients. This analysis of potential donor-derived infection transmission events reported to the Organ Procurement and Transplantation Network demonstrates that delays and errors in communication are frequent, occur at multiple levels in the communication process, and contribute to adverse outcomes among affected transplant recipients.

UR - http://www.scopus.com/inward/record.url?scp=84919683999&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=84919683999&partnerID=8YFLogxK

U2 - 10.1111/ajt.12978

DO - 10.1111/ajt.12978

M3 - Article

C2 - 25376342

AN - SCOPUS:84919683999

VL - 15

SP - 259

EP - 264

JO - American Journal of Transplantation

JF - American Journal of Transplantation

SN - 1600-6135

IS - 1

ER -