Organ/Tissue Donation Referral Checklist
Ensure timely and appropriate referral to organ procurement organization per CMS requirements for all hospital deaths and imminent deaths.
- Industry: Healthcare
- Frequency: Every death/imminent death
- Estimated Time: 10-15 minutes
- Role: Clinical Staff
- Total Items: 29
- Compliance: CMS CoP 42 CFR 482.45, UNOS Policies, OPO Policies
Clinical Triggers
Referral trigger criteria
- Imminent death identified?
- Ventilator-dependent?
- Meeting neurological death criteria?
- Cardiac death/withdrawal of support?
OPO Notification
Timely OPO referral
- OPO called within timeframe?
- OPO case number obtained?
- Clinical information provided to OPO?
- OPO recommendations documented?
Donor Suitability
OPO determination
- Medical suitability determined by OPO?
- Potential organ donor?
- Potential tissue donor?
Family Approach
Authorization process
- Family approach decoupled from death notification?
- OPO staff approached family (if applicable)?
- Authorization obtained?
- All documentation complete?
Pre-Assessment Information
Initial assessment documentation and patient/facility identification
- Assessor Name / Credentials
- Assessment Date
- Department / Unit
- Assessment Type (Routine/Annual/Complaint)
- Previous assessment findings reviewed?
Infection Prevention & Control
Verify infection control practices per CDC and Joint Commission standards
- Hand hygiene compliance observed?
- Appropriate PPE available and properly used?
- Isolation precautions properly implemented?
- Sharps containers available and not overfilled?
- High-touch surfaces properly disinfected?
Patient Safety & Identification
Verify patient safety protocols and identification procedures
- Two patient identifiers used before procedures?
- Fall risk assessment completed?
- Call light within patient reach?
- Bed in lowest position with brakes locked?
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Why Use This Organ/Tissue Donation Referral Checklist?
This organ/tissue donation referral checklist helps healthcare teams maintain compliance and operational excellence. Designed for clinical staff professionals, this checklist covers 29 critical inspection points across 7 sections. Recommended frequency: every death/imminent death.
Ensures compliance with CMS CoP 42 CFR 482.45, UNOS Policies, OPO Policies. Regulatory-aligned for audit readiness and inspection documentation.
Frequently Asked Questions
What does the Organ/Tissue Donation Referral Checklist cover?
This checklist covers 29 inspection items across 7 sections: Clinical Triggers, OPO Notification, Donor Suitability, Family Approach, Pre-Assessment Information, Infection Prevention & Control, Patient Safety & Identification. It is designed for healthcare operations and compliance.
How often should this checklist be completed?
This checklist should be completed every death/imminent death. Each completion takes approximately 10-15 minutes.
Who should use this Organ/Tissue Donation Referral Checklist?
This checklist is designed for Clinical Staff professionals in the healthcare industry. It can be used for self-assessments, team audits, and regulatory compliance documentation.
Can I download this checklist as a PDF?
Yes, this checklist is available as a free PDF download. You can also use it digitally in the POPProbe mobile app for real-time data capture, photo documentation, and automatic reporting.