Redesigning transplant organ labeling to prevent patient harm and organ loss

Rebeca Khorzad*, Enid Montague, Anna P. Nannicelli, Donna M. Woods, Daniela P. Ladner, Alexandra Brown, Jane Louise Holl

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

2 Scopus citations


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 machinereadable barcode on each organ’s label, and a handheld printer for at “point of use” label printing. Outcomes: The new labeling system, TransNet, has becomemandatory since June 2017.Asurvey 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.

Original languageEnglish (US)
Pages (from-to)271-277
Number of pages7
JournalProgress in Transplantation
Issue number3
StatePublished - Sep 2018


  • Efficiency in organ procurement
  • Organ labeling
  • Patient safety
  • Process redesign
  • Quality planning

ASJC Scopus subject areas

  • Transplantation


Dive into the research topics of 'Redesigning transplant organ labeling to prevent patient harm and organ loss'. Together they form a unique fingerprint.

Cite this