New Cardiothoracic Safety Reporting for 'Near Misses'

For instance, Dr. Marshall described a case of a labeling error in the context of transplantation. In this case, both the heart and lungs were procured at one institution but when the heart and lung teams arrived at their home institutions, they found they had brought the wrong cooler back with them; the heart team had the lungs and the lung team had the heart.

As it turned out, the organs went to neighboring institutions so the error was easily rectified, but this was an obvious near miss with a practical, easy to implement solution: label your coolers.

There is a lot to be gained from this project with very little downside; “it's very easy to submit cases, it is very straightforward and totally anonymous” said Dr. Marshall “and the more cases we have, the more we can learn.”