Journal Article
Study

Use of failure mode and effects analysis for proactive identification of communication and handoff failures from organ procurement to transplantation.

Steinberger DM; Douglas SV; Kirschbaum MS.

Failure mode and effects analysis was used to identify vulnerable handoff and communication processes in organ procurement and transplantation. A communication error led to the widely publicized death of a lung transplant patient at Duke University Medical Center in 2003.