Congressional oversight hearing highlights HRSA findings of patient-safety failures in organ procurement; OPTN, OPOs face corrective actions

Congressional subcommittee on oversight and investigations leaders, Health Resources and Services Administration officials and OPTN contractors met at a July oversight hearing to examine HRSA’s March 24, 2025, investigation and a May 28, 2025 corrective action plan into the nation’s organ procurement and transplant system.

The hearing centered on HRSA’s finding that, in a review of 351 authorized-not-recovered (ANR) cases, 103 — nearly 30 percent — had “concerning features,” including failures to recognize improving neurologic function, poor collaboration with hospital teams, inadequate family communications, and weak documentation. The report focused on practices at the Kentucky Organ Donor Affiliates (CODA), now operating as Network for Hope, and on how the OPTN and its contractor handled an index case first raised to the committee in 2024.

The problem and why it matters

The hearing opened with Chairman Joyce describing the session as “Ensuring Public Safety, Oversight of the US Organ Procurement and Transplant System.” Representative Joyce and other members stressed that organ donation saves lives — last year about 48,000 transplants were performed and more than 100,000 people remain on the national waitlist — but said those facts make patient-safety concerns particularly urgent.

Dr. Raymond Lynch, chief of the Organ Transplant Branch at HRSA, described the agency’s review and the corrective action plan HRSA has issued to the OPTN. “This is a technically demanding form of care,” Lynch said. “It’s knowable and fixable. This is something that can be done safely.” He summarized four recurring problems identified in HRSA’s review: inadequate neurologic exams and reevaluations, poor collaboration and respect for hospital teams, deficient family communication, and poor documentation.

Key findings…