Learning from a Tragic Transplant Mistake

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Jesica Santillan at the Duke University Medical Center with her mother, Magdalena

Seventeen-year-old Jesica Santillan was supposed to be one of the lucky ones. After years of living in pain brought on by her failing organs, the teenager finally matched with a heart-lung donor and was admitted to Duke University Medical Center in early February for a double-organ transplant. Thursday morning, after her body rejected the first set of new organs mistakenly implanted with the wrong blood type, Santillan lies in her hospital bed fighting for her life after a second implant procedure. Early reports indicate the second transplant has been successful; Jesica is given a 50 percent chance of survival.

Santillan, whose family was smuggled out of Mexico three years ago, spent the last several days close to death; after the first transplant, her type O-positive blood attacked the type A organs. Tuesday afternoon, her mother pleaded through the media for a new donor. "Please help me find the organs that my daughter needs to live," she said. Those pleas were answered late Wednesday night, when a new double-donor was identified.

Santillan's story is the sort of catastrophic event that concerns anyone who checks into the hospital for a procedure. The first question everyone's asking is: how could this have happened — especially at such an esteemed hospital? Secondly, what can patients do when they enter the hospital to ensure that overworked medical staff doesn’t make a deadly error?

Duke spokesman Richard Puff says the medical center accepts full responsibility for the "tragic" mistake and has already implemented new safety procedures — including a triple-layer system to check blood type matching — to ensure this kind of error will never happen again. The hospital, which performed its first organ transplant in 1965 and now performs the most lung transplants in the country, says there has never been a donor mix-up at the facility before. According to Puff, the investigation is ongoing, and there is no word when the hospital will release new findings on the cause of the error.

When that cause is identified, says Dr. Gerard Magill, Executive Director of the Center for Health Care Ethics at Saint Louis University, it will most likely point to problems in the system — not to doctors with malicious intent. "Virtually every case of medical error can be traced back to a systematic issue," he says. "They're dealing with overloaded staff, too many patients, too much going on. That's a serious problem in almost every American hospital, and it needs to be addressed."

So what are the chances of something like this happening to any one of us? The National Academy of Sciences' Institute of Medicine reports that last year there were 98,000 deaths in hospitals from medical errors — an astonishingly high number (more than the number of deaths from breast cancer, car accidents or AIDS) that's generally given little media attention. Assuming, however, that we are talking about transplants, the prognosis is more promising. According to the United Network of Organ Sharing (UNOS), 23,000 transplants were performed last year alone. And in the history of transplantation, there are only two cases of dangerous blood type mismatches on record since transplantation began (some blood types can be intermingled with few or no consequences).

Still, the Santillan tragedy will prompt transplant patients and their families to wonder, now more than ever, how they can guard against potentially fatal medical errors. As any patient knows, it's bad enough going into the hospital; the last thing you want to worry about is doctors or support staff making a disastrous mistake. John Schochor, an attorney in Baltimore and Washington, D.C. who specializes in medical malpractice cases, offers this advice, not only to transplant patients, but to anyone entering a hospital for an invasive procedure.

  • Find out if the physician or surgeon board certified in their specialty
  • Ask how often your surgeon or physician has done this actual procedure
  • If going into procedure with high fatality rates, consider giving a family power of attorney or drawing up a living will
  • Ask the surgeon how many times they've been sued for medical malpractice

    Back at the hospital, there is a bit of good news for the Duke staff: in the wake of this tragedy, they have received high marks for their conduct since the accident. Duke is doing all the right things — both legally and ethically, says Schochor. "They're analyzing their internal protocol to insure against future errors, and they're accepting responsibility for what happened, which is something we don't often see in cases like this."