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Using root cause analysis to improve survival in a liver transplant program

With the advent of programs such as the American College of Surgeons-National Surgical Quality Improvement Program, surgical services will be compared with their peers across the United States. At times, many programs will experience lower-than-expected outcomes. During July 1, 1998, to June 30, 200...

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Published in:The Journal of surgical research 2005-11, Vol.129 (1), p.6-16
Main Authors: PERKINS, James D, LEVY, Adam E, DUNCAN, Julie B, CARITHERS, Robert L
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creator PERKINS, James D
LEVY, Adam E
DUNCAN, Julie B
CARITHERS, Robert L
description With the advent of programs such as the American College of Surgeons-National Surgical Quality Improvement Program, surgical services will be compared with their peers across the United States. At times, many programs will experience lower-than-expected outcomes. During July 1, 1998, to June 30, 2000 our 1-year graft (76.86%, P = 0.23) and patient (80.61%, P = 0.016) survivals after liver transplantation were lower than our expected rates (graft 81.89% and patient 88.3%), according to the U.S. Scientific Registry of Transplant Recipients (SRTR). We used aggregate root cause analysis to determine underlying reasons for our patient deaths. Two of our surgeons performed a systematic review of all our center's liver transplant patient deaths from January 1, 1995, to December 31, 2000. Each phase of the transplant process was reviewed. Of 355 patients receiving their first transplant, there were 90 deaths, with 188 root causes identified. The apportionment according to phase of the transplant process was patient selection, 50%; transplant procedure, 17%; donor selection, 15%; post-transplant care, 8%, and psychosocial issues, 10%. Risk reduction action plans were developed, and several important changes made in our care protocol. In April 2004, SRTR data revealed that for patients transplanted between January 1, 2001 and June 30, 2003, our 1-year liver graft survival of 90.73% (P = 0.018) was significantly higher than the national expected rate of 84.48%. Our 1-year patient survival rate of 92.66% (P = 0.285) was higher than the expected rate of 89.29%. Lower-than-expected outcomes can provide an impetus for improving patient care and raising the quality of a surgical service. Aggregate root cause analysis of adverse events is a valuable method for program improvement.
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Risk reduction action plans were developed, and several important changes made in our care protocol. In April 2004, SRTR data revealed that for patients transplanted between January 1, 2001 and June 30, 2003, our 1-year liver graft survival of 90.73% (P = 0.018) was significantly higher than the national expected rate of 84.48%. Our 1-year patient survival rate of 92.66% (P = 0.285) was higher than the expected rate of 89.29%. Lower-than-expected outcomes can provide an impetus for improving patient care and raising the quality of a surgical service. 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subjects Biological and medical sciences
Cause of Death
General aspects
Graft Survival
Humans
Liver Transplantation - methods
Liver Transplantation - mortality
Liver Transplantation - statistics & numerical data
Medical sciences
Patient Selection
Postoperative Care
Psychology
Quality of Health Care
Survival Rate
Tissue Donors
title Using root cause analysis to improve survival in a liver transplant program
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