Redesigning Transplant Organ Labeling to Prevent Patient Harm and Organ Loss

Prog Transplant. 2018 Sep;28(3):271-277. doi: 10.1177/1526924818781574. Epub 2018 Jul 16.


Background: In 2012, the Health Resources and Services Administration and the United Network for Organ Sharing launched the "Electronic Tracking and Transportation" (ETT) project, in response to "labeling and packaging issues" being a frequently reported safety incident. This article describes an improvement project conducted as part of this United Network for Organ Sharing project.

Methods: An interdisciplinary team conducted a Process Failure Modes and Effects Analysis, laboratory simulations of organ labeling during procurement, and a heuristic evaluation of a label software application to inform the design of TransNet, a system that uses barcode technology at the point of organ recovery. A total of 42 clinicians and staff from 10 organ procurement organizations and 2 transplant centers in the United States participated. Processes Addressed: Key features of the redesigned labeling system include independent, double entry of label information into the software application, a machine-readable barcode on each organ's label, and a handheld printer for at "point of use" label printing.

Outcomes: The new labeling system, TransNet, has become mandatory since June 2017. A survey conducted on early adopters (N = 11), after 1 year of use, indicates the process is safer and more efficient.

Implications for practice: The findings from this study suggest that the application of quality planning methods, common in other industries, when redesigning a health-care process, are valuable and revelatory and should be adopted more extensively. Future evaluation of TransNet effectiveness to reduce safety incidents is critical.

Keywords: efficiency in organ procurement; organ labeling; patient safety; process redesign; quality planning.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Guidelines as Topic*
  • Humans
  • Patient Harm / prevention & control*
  • Product Labeling / standards*
  • Safety Management / standards*
  • Tissue and Organ Procurement / standards*
  • Transplants / standards*
  • United States