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INTRODUCTION

Prinmum non nocere, first do no harm, the fundamental precept in medicine described by Hippocrates, must be applied to transplantation medicine. As the volume of kidney, heart, liver, and other organ transplantation has increased in the United States, so have complications and adverse outcomes. This is similar to the other disciplines of medicine, the basic principles of risk management, quality, and patient safety must be followed to ensure patient outcomes are of the highest order while managing the risks and uncertainties.

This chapter will review the principles of risk management and patient safety as they apply to liver transplantation, specifically:

  • Biomedical ethical issues in transplantation

  • Medical errors and their prevention

  • Risk and enterprise risk management techniques

  • Informed consent for donor and recipient

  • Diagnostic and medical errors

  • Transparency when errors occur

How does the liver transplant surgeon, their team, and program in which they function deal with or manage the risks inherent in liver transplantation? The answer is risk management and patient safety techniques along with the strict application of biomedical ethics.

BIOMEDICAL ETHICAL ISSUES IN TRANSPLANTATION

The 6 bioethical values are:

  1. Nonmaleficence

  2. Distributive justice

  3. Autonomy

  4. Beneficence

  5. Dignity

  6. Truthfulness/honesty or transparency

Nonmaleficence, or first do no harm, governs the medical profession in general, and certainly liver transplantation, in the ethical treatment of recipients and donors alike. Nonmaleficence is particularly important for the liver transplant surgeon when conflicting interests arise.

Justice in its most basic form is fairness to vulnerable patients. By definition, all patients should be considered vulnerable because they totally rely on the transplant team and enterprise “to do the right thing.” Patients and families must rely on the learned medical and health care professionals, which creates the physician–patient or health care professional–enterprise relationship. Distributive justice is key when it comes to the organ donor waiting lists or, as the United Network for Organ Sharing (UNOS), website states, “A national computer system and strict standards are in place to ensure ethical and fair distribution of organs.” Distributive justice also concerns itself with the distribution of scarce health resources such as livers and the decision of who gets what treatment or transplantation within the bounds of fairness and equality.

Autonomy is permission from the patient and donor (live or deceased) to go forward with harvesting the liver and transplanting it. Medically and legally, it is known as the doctrine of informed consent. The patient has the right to refuse or choose treatment, accepting your recommendation to transplant a liver, or a donor's right to donate a liver or portion thereof. However, patient autonomy or informed consent/refusal is only within the bounds of the standard of professional practice or care. If the physician believes that the patient, patient's surrogate decision maker, or family is asking the transplant team to participate in or perform a ...

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