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To analyze heart-beating organ donation patterns in four countries using the Donor Action (DA) Program nationally and to identify areas for improvement.Medical Record Review (MRR) of 18,118 critical care deaths between January 2006 and December 2007 in Belgium, Finland, France, and Switzerland. Data were entered to the DA System Database for analysis.Of 6561 patients without contraindications to donation, 45.3% met preconditions for brain death (BD) diagnosis, 31.4% had signs of severe brain damage and 28.8% met criteria for formal BD diagnosis. Belgium had the highest number of patients with formal BD diagnosis (75.7%) and Switzerland (57.4%, P<0.0001) the lowest. Although donor identification rates were uppermost in France (93.6%) and lowest in Finland (47.7%, P<0.0001); Finland excelled in donor referral (93.9% of identified cases) versus only 63.8% in Switzerland (P<0.0001), and excelled in family approach rates (92.7%) versus only 70.2% in France (P<0.0001). Consent rates were superior in Belgium and Finland and lowest in France (P<0.0001). Conversion rates (percent of potential donors vs. actual donors) were higher in France and Belgium and significantly lower in Finland and Switzerland (P=0.0187). Only Belgium had a non–heart-beating donation policy during the study period, resulting in 11.2% more donors added to the country’s donor pool.The DA MRR proved to be an excellent tool to identify areas of improvement within certain steps of the donation process. Moreover, DA’s MRR has shown to be applicable in different countries and environments and should be considered as a unique tool for comparing countries’ donation performance.