Policies,Administrative,UWHC,Department Specific,Transplant,Transplant - Solid Organ

Disease Transmission Reporting Policy (3.21)

Disease Transmission Reporting Policy (3.21) - Policies, Administrative, UWHC, Department Specific, Transplant, Transplant - Solid Organ


Effective Date: December 2015
Revised Date: Title: Disease Transmission Reporting Policy Policy Number: 3.21

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The purpose of this policy is to outline the steps University of Wisconsin Transplant Program will
take when a suspected potential disease transmission between an organ donor and an organ
recipient has been identified post-transplant. It is within this policy to adhere to the University of
Wisconsin Hospital & Clinics (UWHC) standards of patient care, as well as the standards determined
by regulatory and accrediting agencies, such as The Joint Commission (TJC), the Organ Procurement
and Transplantation Network (OPTN)/United Network for Organ Sharing (UNOS), and the Centers
for Medicare & Medicaid Services (CMS).

This policy applies to all solid organ transplant recipients as well as any staff member who is made
aware that a potential disease transmission has occurred between a transplant recipient and organ

UNOS Policy 15.4.A and UWHC OPO Policy 5.07

A. When an organ recipient is suspected to have, is confirmed positive for, or has died from a
potential transmissible disease or medical condition, including infections and malignancies, and
there is substantial concern that it could be from the transplanted organ, then the transplant
program must do all of the following:
1. Discovery or notification of potential disease transmission should immediately be discussed
with the attending staff physician to make a determination as to whether there is felt to be
substantial risk that this was indeed donor-derived.
a. This determination must be documented in the recipient’s chart.
b. If determination cannot be made immediately, or requires further investigation, the
incident should be reported as a potential transmission.
2. Notify the institution that recovered the organ (OPO or living donor recovery hospital),
without waiting for all medical documentation that may eventually become available. The
transplant program must notify the living donor hospital or UNOS safety contact listed for
the host OPO by phone and provide documentation as soon as possible but no later than 24
hours after learning of the event.
3. Report the event to the UW Transplant program manager (Patient Safety Officer for
abdominal transplant) and UWHC Patient Safety Net (PSN) as soon as possible but no
later than 24 hours after learning of the event. If the manager is unavailable, the UW
Transplant Operations Director should be contacted. The UW Transplant manager is

Effective Date: December 2015
Revised Date: Title: Disease Transmission Reporting Policy Policy Number: 3.21

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responsible for reporting the event through the OPTN Improving Patient Safety Portal
within 24 hours of the event occurrence.
B. If the transplant program goes on to provide treatment to the recipient for a potential
disease transmission, the transplant program is responsible for all of the following:
1. Responding to host OPO, living donor recovery hospital, and OPTN patient safety staff
requests for information regarding all recipients in a timely fashion and communicating
updated information regarding recipient condition, test results, diagnosis, and plans for
treatment and follow up.
2. Submitting copies of any relevant test results (including cultures, serologies, imaging
studies, or autopsy results) to OPTN patient safety staff.
3. Notifying recipients involved in cases of confirmed disease transmissions and
documenting this notification in the recipient medical record according to Policy 15.3.A:
Deceased Donors with Additional Risk Identified Pre-transplant Follow-Up Report within
45 days of the initial date the potential transmission was reported.
OPTN patient safety staff may request additional information related to the recipient
beyond 45 days, in an effort to determine the probability of donor-derived disease
transmission, depending on the potentially transmitted disease or malignancy.

University of Wisconsin Transplant Program

Transplant Managers
Operations Director


________________________________ _________________________________
Jill Ellefson, MBA Dixon Kaufman, M.D., PhD
Director, Organ Donation and Transplant Service Line Chair, UW Transplant Program

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