University of Transplant Center Quality Improvement Program
ADULT KIDNEY TRANSPLANT PROGRAM – GRAFT FAILURE OR RECIPIENT DEATH REVIEW FORM
Directions
1. Complete page 1 for all graft failures or recipient deaths.
2. Complete pages 2 – 5 if the graft loss or death occurred within the first 365 days of transplant.
3. Once completed, submit the form as an e-mail attachment to
Patient Information
Name
Age: Choose an item.
CPI No.:
Years
Primary Diagnosis: Choose an item.
Gender: Choose an item.
Secondary Diagnosis: Choose an item.
General – Transplant Information
Date of Transplant
Prior Kidney Transplant(s): Choose an item.
Kidney(s) Transplanted: Choose an item.
Other Prior Transplant(s): Choose an item.
ABO: Choose an item.
Cross Match: Choose an item.
Donor Information
Decease Donor Criteria: Choose an item.
Donor Type: Choose an item.
Donor Age
Preservation Method: Choose an item.
Positive Donor Serology: Choose an item.
CDC High Risk Donor: Choose an item.
If Graft Failure Occurred
Date of Graft Loss:
Primary Cause of Graft Loss: Choose an item.
Event Occurred Within: Choose an item.
If Other, Specify: Click here to enter text.
Graft Failure: Choose an item.
Contributory Cause of Graft Loss: Choose an item.
If Other, Specify: .
If Death Occurred
Date of Death: Click here to enter a date.
Primary Cause of Death: Choose an item.
Event Occurred Within: Choose an item.
Contributory Cause of Death: Choose an item.
If Other, Specify: Click here to enter text.
Comments (Optional)
Click here to enter text.
CASE HISTORY
Unauthorized disclosure or duplication of confidential quality/peer review documents of the contained in, or attached to, this
communication is absolutely prohibited. These documents are protected from disclosure pursuant to the provisions of
MCL333.20175; MCL333.21513; MCL333.21515; MCL331.531; MCL331.533, or such other statutes that may be applicable.
Page 1 of 5
University of Transplant Center Quality Improvement Program
Describe Occurrence
Click here to enter text.
Additional – Transplant Information
PRA %: Click here to enter text.
Recovery Team: Choose an item.
DSA: Choose an item.
Warm Ischemic (hrs:min): Click here to enter text.
Induction Therapy: Choose an item.
Total Ischemic (hrs:min): Click here to enter text.
Patient Location
If Other, Specify: Click here to enter text.
If Not Admitted to
Information Source: Click here to enter text.
Last Seen: Click here to enter a date.
Describe Known Events: Click here to enter text.
If Admitted to
Admission Date: Click here to enter a date.
Admission Diagnosis
Admitting Service:
Attending Physician: Click here to enter text.
Discharge Date: Click here to enter a date.
Discharge Disposition: Click here to enter text.
Discharge Service: Click here to enter text.
Discharge Physician: Click here to enter text.
Length of Stay in Days: Click here to enter text.
Co-Morbidities
Diabetes: Choose an item.
Obesity: Choose an item.
Prior Cancer: Choose an item.
Prior Cancer: Choose an item.
Ischemic Heart Disease: Choose an item.
Vascular Disease: Choose an item.
Hepatitis/Chronic Liver: Choose an item.
PMH: Choose an item.
PMH: Choose an item.
Other Specify: Click here to enter text.
Primary Complications
Transplant to Discharge: Choose an item.
Transplant to Discharge: Choose an item.
Transplant to Discharge: Choose an item.
Transplant to Discharge: Choose an item.
Transplant to Discharge: Choose an item.
Transplant to Discharge: Choose an item.
Unauthorized disclosure or duplication of confidential quality/peer review documents of the contained in, or attached to, this
communication is absolutely prohibited. These documents are protected from disclosure pursuant to the provisions of
MCL333.20175; MCL333.21513; MCL333.21515; MCL331.531; MCL331.533, or such other statutes that may be applicable.
Page 2 of 5
University of Transplant Center Quality Improvement Program
Discharge to 90 Days: Choose an item.
Discharge to 90 Days: Choose an item.
Discharge to 90 Days: Choose an item.
Discharge to 90 Days: Choose an item.
Discharge to 90 Days: Choose an item.
Discharge to 90 Days: Choose an item.
90 to 365 Days: Choose an item.
90 to 365 Days: Choose an item.
90 to 365 Days: Choose an item.
90 to 365 Days: Choose an item.
90 to 365 Days: Choose an item.
90 to 365 Days: Choose an item.
Compliance Issues
Describe: Click here to enter text.
Other Factors/Considerations
Unauthorized disclosure or duplication of confidential quality/peer review documents of the contained in, or attached to, this
communication is absolutely prohibited. These documents are protected from disclosure pursuant to the provisions of
MCL333.20175; MCL333.21513; MCL333.21515; MCL331.531; MCL331.533, or such other statutes that may be applicable.
Page 3 of 5
University of Transplant Center Quality Improvement Program
CONTRIBUTING FACTORS
Were technical issues (surgical or non-surgical) a
factor in this event?
Choose
an item.
If yes, describe.
Click here to enter text.
Recommendation: Choose an item.
Was medication dosing or protocols a factor in this
event?
Choose
an item.
If yes, describe.
Click here to enter text.
Recommendation: Choose an item.
Was coagulopathy a factor in this event?
Choose
an item.
If yes, describe.
Click here to enter text.
Recommendation: Choose an item.
Were policies, protocol, or guidelines a factor in this
event?
Choose
an item.
If yes, describe.
Click here to enter text.
Recommendation: Choose an item.
Were human resources an issue in this event?
Choose
an item.
If yes, describe.
Click here to enter text.
Recommendation: Choose an item.
Was communication a factor in this event?
Choose
an item.
If yes, describe.
Click here to enter text.
Recommendation: Choose an item.
Was a lack or misinterpretation of information a
factor in this event?
Choose
an item.
If yes, describe.
Click here to enter text.
Recommendation: Choose an item.
Was lack or inadequate training a factor in this
event?
Choose
an item.
If yes, describe.
Click here to enter text.
Recommendation: Choose an item.
Was availability or use of equipment a factor in this
event?
Choose
an item.
If yes, describe.
Click here to enter text.
Recommendation: Choose an item.
Was the physical environment a factor in the event?
Choose
an item.
If yes, describe.
Click here to enter text.
Recommendation: Choose an item.
Other factors specify.
Choose
an item.
If yes, describe.
Click here to enter text.
Recommendation: Choose an item.
Unauthorized disclosure or duplication of confidential quality/peer review documents of the contained in, or attached to, this communication is absolutely prohibited. These
documents are protected from disclosure pursuant to the provisions of MCL333.20175; MCL333.21513; MCL333.21515; MCL331.531; MCL331.533, or such other statutes that
may be applicable.
Page 4 of 5
University of Transplant Center Quality Improvement Program
CORRECTIVE ACTION PLAN
Contributing Factor
Corrective Action
Responsible
Individual(s)
Outcome Measure
Measure Date
Comments
Click here to
enter a date.
Click here to
enter a date.
Click here to
enter a date.
Click here to
enter a date.
Click here to
enter a date.
Reviewed on:
Click here to enter a date.
Approved by:
☐ , MD, Surgical Director, Adult Kidney Transplant Program
☐ , MD, Medical Director, Adult Kidney Transplant Program
Unauthorized disclosure or duplication of confidential quality/peer review documents of the contained in, or attached to, this communication is absolutely prohibited. These
documents are protected from disclosure pursuant to the provisions of MCL333.20175; MCL333.21513; MCL333.21515; MCL331.531; MCL331.533, or such other statutes that
may be applicable.
Page 5 of 5