Redesigning Transplant Organ Labeling to Prevent Patient Harm and Organ Loss

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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.


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 machine-readable barcode on each organ’s label, and a handheld printer for at “point of use” label printing.


The new labeling system, TransNet, has become mandatory since June 2017. A survey 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.

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