Probabilistic risk assessment of accidental ABO-incompatible thoracic organ transplantation before and after 2003

Richard I. Cook, John Wreathall, Alison Smith, David C. Cronin, Oswaldo Rivero, Robert C. Harland, Jai Raman, James Battles, James Reason

Research output: Contribution to journalArticle

16 Scopus citations

Abstract

BACKGROUND. A widely reported ABO-mismatch accident in March of 2003 raised concerns about the reliability of the transplantation system. Because this type of failure is rare and significant, we performed a probabilistic risk assessment (PRA) of the donor-recipient matching processes for thoracic organ transplantation. METHODS. A probabilistic risk assessment was performed. RESULTS. The likelihood of accidental incompatible implantation was already low in 2003. The PRA model indicates that the likelihood of such an event was 1.38×10 per donated organ. This estimate correlates closely with the observed rate of these accidents. Based on this model, process changes put in place shortly after the accident reduced the probability to ∼3.08×10 and changes put in place in October 2004 further reduced the probability to ∼2.22×10 per organ donated. CONCLUSIONS. The observed and predicted likelihoods of accidental incompatible thoracic organ transplantation are comparable. These likelihoods are several orders of magnitude smaller than other hazards associated with solid organ transplantation. The PRA model indicates that changes that followed the March 2003 accident further reduced the likelihood of accidental incompatible implantation by roughly two orders of magnitude. Quantitative estimates from PRA can be used to assess risks in healthcare and to gauge the impact of system changes on these risks.

Original languageEnglish (US)
Pages (from-to)1602-1609
Number of pages8
JournalTransplantation
Volume84
Issue number12
DOIs
StatePublished - Dec 1 2007
Externally publishedYes

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Keywords

  • Accident
  • Error
  • Mismatch
  • Prevention
  • Probabilistic risk assessment

ASJC Scopus subject areas

  • Transplantation

Cite this

Cook, R. I., Wreathall, J., Smith, A., Cronin, D. C., Rivero, O., Harland, R. C., Raman, J., Battles, J., & Reason, J. (2007). Probabilistic risk assessment of accidental ABO-incompatible thoracic organ transplantation before and after 2003. Transplantation, 84(12), 1602-1609. https://doi.org/10.1097/01.tp.0000295931.39616.25