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(AHCRQ) to implement policies such that the failure to identify a potential organ donor and/or refer such a potential donor to the OPO in a timely manner be considered a serious medical error. Such events should be investigated and reviewed by the hospitals in a manner similar to that for other major adverse healthcare events.

9. That the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) strengthen its accreditation provisions regarding organ donation, including consideration of treating as a sentinel event the failure of hospitals to identify a potential donor and/or refer a donor to the relevant OPO in a timely manner. Similar review should be considered by the National Committee on quality Assurance (NCQA).

10. That specific methods be employed to increase the education and awareness of patients at dialysis centers as to transplant options available to them.

11. That research be conducted into the causes of existing disparities in organ transplant rates and outcomes with the goal of eliminating those disparities.

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