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Analysis and dissemination of transplant patient safety data are essential to understanding key issues facing the transplant community and fostering a “culture of safety.” The Organ Procurement and Transplantation Network's (OPTN) Operations and Safety Committee de‐identified safety situations reported through several mechanisms, including the OPTN's online patient safety portal, through which the number of reported cases has risen sharply. From 2012 to 2013, 438 events were received through either the online portal or other reporting pathways, and about half were self‐reports. Communication breakdowns (22.8%) and testing issues (16.0%) were the most common types. Events included preventable errors that led to organ discard as well as near misses. Among events reported by Organ Procurement Organization (OPOs), half came from just 10 of the 58 institutions, while half of events reported by transplant centers came from just 21 of 250 institutions. Thirteen (23%) OPOs and 155 (62%) transplant centers reported no events, suggesting substantial underreporting of safety‐related errors to the national database. This is the first comprehensive, published report of the OPTN's safety efforts. Our goals are to raise awareness of safety data recently reported to the OPTN, encourage additional reporting, and spur systems improvements to mitigate future risk.

Recent Developments and HRSA MandateIn the early and mid-1990s, several

A carefully controlled double‐blind study of the usefulness of a new device as an aid in screening for cervical cancer was carried out. The device measures and displays multiple spectrophotometric properties of cells in liquid suspension at rapid rates. The results of a test involving cervical swab and vaginal wash specimens from 1155 patients are presented. Cytologic smears, obtained concurrently with samples for the device and processed by the Papanicolaou technique, were independently evaluated. Biopsy results on those patients considered by cytology to have cancer were used in evaluating the device. Forty‐five per cent of the swab samples were readable by the device; of these it selected 35%, which included 85% of the readable cases with cancer. With vaginal wash samples 50% of the known cancers were missed. These results reflect the efficiency of the cell, sampling procedure as well as the performance of the device itself; inefficient sampling procedures account for the low percentage of readable swab samples and for some of the cases that were missed with these samples, as well as the poor results obtained with the vaginal wash samples.

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