ANATOMY OF A MISTAKE
The Jesica Santillan Tragedy
“Mistakes aren’t mistakes, they are lessons!”. A rewind to fifteen years ago, 2003 when surgeons at Duke University Hospital, a world-renowned medical center, transplanted mismatched heart and lungs into a 17-year-old Jesica Santillan resulting in her tragic death. The hospital admitted what few hospitals ever admit: It had made a mistake!
Jesica’s death as a result of receiving mismatched organs was a tragedy not only for Jesica and her family, but also for her transplant surgeon, James Jaggers, for Duke Medical Center, and for the whole organ transplantation community. Her death exemplified the importance of designing systems that prevent medical error; the moral, legal, and psychosocial perplexities of dealing with medical error; the fragility of trust in health care institutions; and some of the dilemmas involved in organ procurement and allocation.
Jesica Santillan was a seventeen-year-old young lady who was born in Mexico with restrictive cardiomyopathy. She came to the United States from Mexico four years ago, smuggled into the country illegally by her parents in search of treatment. They moved to North Carolina, and lived in a trailer. The family's plight caught the attention of a local builder, Mark Mahoney, who started a charity that raised money to get Jesica a transplant at Duke.
In May 2002, Jesica’s doctors at Duke placed Jesica on a waiting list for a heart-lung transplant. On 6 February 2003, the Santillans got a call from a transplant team informing them that they had found organs for Jesica. The surgeons had given Jesica Santillan donated organs with the wrong blood type, causing her body to reject the new heart and lungs, and her system to shut down.Two weeks after the operation, she received a second transplant - this time with the correct blood type. But it was too late to save her life.
How could this have happened, especially at one of the most prestigious hospitals?
Nobody knows the answer better than Dr. James Jaggers, the transplant surgeon who put that heart and those lungs into Jesica. Dr. Jaggers, a highly regarded chief of pediatric cardiac surgery at Duke, has performed more than 100 heart transplants. He says that everything was going smoothly during the operation until five hours into it, when he got a call from a technician in the immunology lab saying that something was terribly wrong. Jesica's blood type, type O, did not match the blood type of her new organs, which were type A.
At that point, Dr. Jaggers says, "We had already put in the new organs and we had actually come off the heart-lung machine, off bypass. And we were planning to get ready to close the chest and move up to the ICU. And it was about that point, about an hour, an hour and 15 minutes after we had put the organs in, that we got the call that this was an incompatible transplant. And we, of course, knew what that meant at that point."
Dr. Jaggers says he was devastated"It's almost like a death and dying reaction. It's that deep, sort of sinking feeling, and it's a completely helpless feeling-that there's absolutely nothing you can do about it." Then, he had to tell the family what had happened. "I think my exact words were that there has been a problem, in that the organs we put into Jesica were type A organs and she's type O, and that's an incompatible transplant, and it's something that we didn't plan to do. It's an error. But we're going to do everything we can to make this work."
How did an operation performed by a team of expert surgeons go so wrong?
What it came down to was a failure to communicate basic information. Not one of more than a dozen people working at Duke Hospital and at the two organizations responsible for getting the new heart and lungs to Jesica ever cross-checked her blood type before the surgery to see if it was a match with the blood type of the donor.
The events were set in motion when Dr. Jaggers received a phone call in the middle of the night. Carolina Donor Services, the local agency responsible for placing organs with compatible recipients, said it had found a donor in Boston for another one of Jaggers' patients. Dr. Jaggers said he couldn't use the organs for that patient, and asked the agency if the heart and lungs would be appropriate for Jesica Santillan. Several hours later, he was told he could have the organs.
Carolina Donor Services says Dr. Jaggers was informed of the donor's blood type. But Dr. Jaggers has no memory of them talking about it. He did not ask for any blood type information, he says, because "I had satisfied in my own mind that if they had offered the organs for me that she was a match."
He is still agonizing over that conversation. "I'm ultimately responsible for this because I'm Jesica's doctor and I'm arranging all this," he says. "But honestly, I look back, and yeah, if I'd made one more phone call or if I had told somebody else to make a phone call or done something different, maybe it would have turned out differently. But you know, those are all 20/20 hindsight."
As soon as Dr Jaggers found out that a heart and lungs were available for Jesica Santillan, he sent a member of his transplant team, Dr. Shu Lin, to procure them from the New England Organ Bank in Boston. While he was there, Dr. Lin was informed of the donor's blood type at least three times. Incredibly, he'd never been told Jesica's blood type, and so he didn't know the organs were a mismatch. And that was yet another flaw in the system, according to Dr. Duane Davis, head of Duke's transplant unit.
"Should we as a group have made it mandatory that the procuring surgeon knew that? Yes. But it wasn't Dr. Lin's fault that he didn't know, because that information wasn't conveyed to him," says Davis.
From the donor to the recipient there must have been at least a dozen doctors and nurses from Duke who were involved. Why did not one among them see that the donor didn't match the recipient?Dr. Davis notes that there was an initial misassumption, and no one went back to check it. The initial mistake, Davis says, was made by Dr. Jaggers. "I would say that it's routine for those of us who do this on a regular basis to ask what the blood type is," says Davis. Nonetheless, he acknowledges that it was a failure of the system as well as the individual.
What may be most disturbing is that UNOS, the national organization that oversees Carolina Donor Services and the New England Organ Bank, already had firm policies in place that should have prevented what happened to Jesica Santillan. Their policy requires that the blood types of donors and recipients be matched before releasing any organs. Lloyd Jordan, who runs Carolina Donor Services, admits that the company did not ensure that there was a match: "We could have requested her blood type, and I wish we had, but we did not do that."
In the days following her operation, Jesica's condition rapidly deteriorated, and doctors said her only hope for survival would be a second transplant. All the while, Duke had said nothing publicly about the mistake, and by the time Jesica received a second transplant nearly two weeks later, she was near death. On February 20, Duke physicians, including Jaggers had performed a second operation. Her body appeared to tolerate the second set of organs. On February 21, Jesica developed brain swelling and intracranial bleeding. Duke spokespeople announced that Jesica had suffered a severe and irreversible brain injury. On February 22, Duke physicians determined that Jesica had died.
If there is anything good that comes out of Jesica’s death, it is an opportunity for health care providers and organizations to learn (or relearn) some important lessons. Some of these lessons are so obvious that they would be apparent to an eighth grade biology student; others are more subtle and vexing.
The main obvious lesson is that health care providers and organizations need to do a better job of building systems that will reduce the risk of medical error and improve patient safety. The error that occurred was analogous to amputating the wrong limb: it does not take years of medical training to understand the fundamental mistake of ABO incompatibility. Duke’s organ transplantation procedures depended on surgeons and organ procurement agencies not making such mistakes. But any procedure that depends on human perfection is doomed to fail.
The Santillan case illustrates vividly the most important point made by the Institute of Medicine in its report on medical error, namely, that the best way to improve patient safety is to focus on how systems can cause or prevent error. Duke’s new system for organ procurement, with its multiple checks for ABO compatibility, is much better. Other institutions would be wise to follow Duke’s example.
Yet another lesson to learn from this case is that institutions must take special care to repair trust once it has been broken.
Another obvious lesson is that it is very important to strive for honesty and candor when communicating with patients about medical mistakes. Medical mistakes can destroy the trust that patients and families have in providers and organizations. If patients and families suspect that a provider or organization is attempting a cover-up, they may become distrustful and vindictive. Jaggers, to his credit, admitted his mistake to the Santillans soon after it happened. His honesty and candor showed a great deal of courage and integrity.
What does Dr. Jaggers have to say to Jessica's family?
"I can understand their sadness and their despair about all this," he says. "And I think that all of us have a really tragic sense of loss about this. But I'm confident that we did everything we possibly could for Jesica. We acknowledged that an error was made. We did everything we could to save her, to get her new organs, to treat her medically. And as tragic as it is, sometimes things don't go the way you want them to."
Story since then
Since the death of Jesica Santillan, Duke Hospital has put steps into place to prevent such a tragedy from happening again. Everyone directly involved in the organ transplant process is now required to check and double check the blood type of an organ donor and recipient before a transplant ever takes place.
Unfortunately, it was too late for Jesica Santillan.
Following investigations triggered by the death of Jesica Santillan, federal government regulators cited Duke University Hospital for multiple deficiencies in its organ transplant procedures. The hospital has since taken corrective action and is now in full compliance with all regulations.
Jesica Santillan was a young woman from a foreign land in desperate need of a new heart and new lungs. She came to James Jaggers and Duke Medical Center for help. Duke opened its doors to her, and Jaggers extended to her the same kindness and skill that he had extended to all of his other patients, people living in other countries included. Although her life ended tragically, we can hope that her death was not in vain. Her story, as tragic as it is, can teach us important lessons about patient safety, medical fallibility, honesty, and trust.
Sources: https://pxmd.co/7KBGr https://pxmd.co/vC5r6