Established Date: March 2007
Effective Date: January 2018
Title: Occurrence Reporting System (PSN) Policy Number: 1.08
Electronically Approved By: Michael E. Anderson, PA-C Anthony M. D’Alessandro, M.D.
Executive Director Medical Director
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The purpose of this policy is to ensure University of Wisconsin Organ and Tissue Donation (UW OTD) staff
will report occurrences to identify areas of operational vulnerability and opportunities for system
improvements for continuous quality improvement to achieve operational safety, effectiveness, efficiency,
to decrease occurrences, and to improve the professional practice of each staff member. UW OTD will use
the Patient Safety Net (PSN) system to report occurrences and will follow University of Wisconsin Hospital
and Clinics (UWHC) policy 4.22 and all applicable regulatory requirements.
“Occurrence”: An actual or near-miss variation in UW OTD standard operations and/or standard operations
of UW OTD partners (such as donor hospitals, tissue and eye banks, transplant centers, couriers, or testing
facilities) that involve any elements related to the donation process. This may include but is not limited to
variations related to documentation, required actions, and communication. The term “occurrence” and
“PSN” may be used interchangeably for this definition.
A. Every UW OTD staff member will be accountable for his/her actions and will identify and promptly
B. Staff will report occurrences in the PSN system per the current UW OTD – Instructions for Entering a
PSN, which is located on the Organ Donation and Transplant Quality page in UConnect.
C. Occurrences may be reported anonymously.
D. After an occurrence is reported and routed to the appropriate UW OTD manager or designee, s/he will
complete all appropriate follow-up per his/her discretion and will complete the appropriate
documentation in the PSN system within 45 days after the occurrence was submitted.
E. Occurrence data will be maintained in the PSN system and is accessible to designated staff for the
purposes of review, analysis, and reporting which will be completed on a quarterly basis and as needed.
F. Additional occurrence data analysis may be completed per UWHC policy 4.22 by the UWHC Healthcare
Event Evaluation Team (HEET).
UWHC Policy 4.22