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Blood SampleThe nationally-publicized death of an immigrant teen drives a well-recognized hospital and other medical facilities countrywide to re-examine and revamp their organ and blood donation procedures, putting in place technical and communications systems to avert similar tragedies.

Jesica Santillan, aged 17, died little over a decade ago after her health deteriorated when a team of doctors at Duke University Hospital in North Carolina provided her by mistake with a badly-needed heart and two lungs at the time of transplant surgery from a donor with the wrong blood type.

In February 2003, when Santillan received the wrong donations because her blood was type O and the owner of the organs had type A blood, her body began to reject the new heart and lungs and her system shut down.

Alarmed, the lead doctor and the medical team worked with the organ donor services and hospital administrators and staff to secure a second transplant for her. Two weeks after the initial surgery, the team conducted a second transplant for Santillan with the correct blood type. However, it was not enough to save her life in time.

The antibodies in her blood attacked and destroyed her new organs and compromised her immune system, plunging her into a light coma and severely damaging her brain to the point of brain death.

Dr. James Jaggers, the lead doctor in question and a renowned chief of pediatric cardiac surgery at Duke who, in his career, performed more than 100 heart transplants, said that all was well with the operation until five hours into the procedure when he received a phone call from a technician in the immunology lab, indicating the grave error of the wrong blood type match.

At the time, Dr. Jaggers reported that the surgical team had already placed in the new organs in her body and took her off the heart-lung machine and bypass. The team planned to close the chest and send Santillan to the intensive care unit when they received the call.

Dr. Jaggers said that the team realized that Santillan’s life was in danger.

The team, led by the doctor, informed the family of the mistake, including the wrong blood type match and its consequences, with a promise and a plan in action to reverse course.

Santillan was on the verge of undergoing a medical triumph. She arrived in the United States from Mexico four years previously on account of her parents who smuggled her into the country in a desperate bid to find treatment for a life-threatening heart and lung condition that her native land could not correct.

The family moved to North Carolina and lived in a trailer. A local builder became aware of their circumstances and began a charity to raise funds to find the ailing teen a transplant at Duke.

In hindsight, Dr. Jaggers, his team and medical policymakers nationwide determined that the cause of Santillan’s death was a breakdown in communication. None of the more than dozen staffers at Duke nor the two organ donation sites who procured the new heart and lungs for Santillan checked her blood type before surgery to decide whether it was the appropriate match.

The chancellor for health affairs at Duke acknowledged the hospital’s participation in the error, saying that, at the time, a system of checks would have kept the mistake and tragedy from occurring.

The incident began when Dr. Jaggers was phoned in the middle of the night about the blood type mismatch. Carolina Donor Services, the local agency assigned to match patients with donors, notified him that a donor was located in Boston for a patient other than Santillan.

Dr. Jaggers replied that he could not use the organs for that particular patient but asked the agency if the heart and lungs could be used for Santillan. Hours later, he learned he could use the organs.
Carolina Donor Services claimed the doctor was informed of the blood type but he said that he does not recall discussing it with the agency, confident that the organs were the right match for Santillan. Dr. Jaggers since regretted the decision, wishing he had made another phone call or asked an ancillary health employee to conduct the call.

Dr. Jaggers then sent Dr. Shu Lin, a member of his transplant team, to collect the organs from the New England Organ Bank in Boston.

However, when he arrived there, Dr. Lin was told of the donor’s blood type three times. Yet, he said he had never been told of her blood type and, thus, he did not know of the mismatch. This meant another flaw in the organ donation process, the head of Duke’s transplant unit said.

Oddly still, UNOS, a national organization overseeing Carolina Donor Services and the New England Organ Bank, already adopted and executed a policy that would have prevented the errors that resulted in Santillan’s death. Under UNOS policy, the blood types of donors and recipients must be matched before any other organs can be released.

The entire time that the tragedy unfolded, Duke hospital did not publicly acknowledge the mistake until the family released word of it to the media.

The family and their attorneys fingered Duke hospital for not publicizing their error, arguing that, if the medical facility had done so sooner, the public would have identified another set of organs for Santillan.

Tests did reveal that Santillan’s brain damage was too severe to be reversed. In fact, Dr. Jaggers and his team announced that they would stop the treatment and machines used to help Santillan breathe.

The father accused Duke’s medical team of allowing Santillan to lie in bed for 11 days before resolving the problem. The mother thought the hospital was seeking to kill her daughter, stating the team took her off the machines to get rid of her and the problem.

Dr. Eva Grayck, the attending physician in the pediatric intensive care unit, was ultimately assigned to turn off the machines. Santillan’s funeral was held four days later.

The Santillan case demonstrates that, with the recession still in effect from 2008, government and commercial budget cuts, layoffs and programmatic cancellations or reductions are leading hospitals and facilities to make mistakes. Additionally, errors take place because of human fallibility and hospitals and facilities not having developed the variety of systems needed to catch them, experts say.

With the widely-known death of Santillan, federal regulators probed Duke hospital and cited the facility for several deficiencies in its organ transplant processes.

Since then, the hospital has worked with federal, commercial and nonprofit agencies to implement and carry out policies that would prevent such an incident in the future. At every step in the organ donor and transplant processes, each medical specialist and ancillary health employee is expected to check the blood type of an organ donor and the recipient repeatedly before surgery begins.

Experts say that such processes were not in place before because of the historical manner in which such errors were handled in the past. Medical staff, leadership and management tend to react to a health issue in the absence of a system of communication or action.

Despite compliance by hospitals and medical facilities of new national directives concerning organ donations and transplants, experts say that the Santillan case has raised many questions, issues and opportunities for dialogue as research shows 100,000 people a year die from medical mistakes and, unlike the case, very few ever know about them.

For example, Dr. Jaggers and his medical team revealed in a statement released in the aftermath of Santillan’s death that they have had to deal with questions about medical error and prevention, ethical questions about organ transplants and end-of-life issues, and communications policies juggling a patient’s right to privacy, the needs of the family and a public’s right to know.

In some instances, Dr. Jaggers and his team maintain that they sought the appropriate solutions and were successful in some but flawed in others. All the while, they said they tried to be honest with the Santillans and strived to provide the dying teen with optimum medical care.

One of the challenges they faced was the publicly-known shortage of organs to save the lives of all patients in need of a transplant.

With few members of the public becoming organ donors, Dr. Jaggers and his team cite 17 people dying daily in wait of transplants that will never occur. This disparity and the blood type mistake in the Santillan case forced Duke hospital to face a unique situation in organ donation and transplantation.

As a result, Dr. Jaggers said that critics of the hospital are divided between some who believe the medical team could have achieved more in saving Santillan and those who are convinced Duke overreacted.

The team explained that some critics ask why the hospital did not announced the blood type mismatch after the first transplant and started a campaign to find the appropriate organs.

Dr. Jaggers countered that Santillan’s family asked the medical team not to. Additionally, he explained that it was considered improper for the team to generate publicity around the family’s tragedy. The organ donor process used by all medical facilities was meant to seek and locate organs fairly based on the level of need.

Dr. Jaggers added that it is considered inappropriate medical policy for the hospital to ask the public for organs for particular patients because it would create an unfair advantage for others also in wait of organs. He said it was best to rely on the system among the organ donor services and the medical facilities.

In the week of the original transplant, the hospital worked with the Santillan family, revealing in four news reports that the teen-aged girl was rejecting her organs but complying with the family’s wish not to explain, Dr. Jaggers said.

Later, a spokesperson for the family told about the organ donor mistake to the media. The report was first made by a local television station and appeared on the front page of a local newspaper. The following day, the hospital recognized the error and expounded upon it.

Many commented that the hospital should not have given Santillan a second transplant since the second set of organs could have benefitted another patient who had a better chance of surviving the odds of such a surgical procedure.

Dr. Jaggers responded that Santillan was treated as any other sick patient and endured the right tests to determine her eligibility and her advantages in taking part in another transplant.

He said that, when Duke hospital informed UNOS of Santillan’s need for a second transplant, her critical condition ranked her high on the donor and transplant list. UNOS declared Santillan fit for a second transplant and the new set of organs were available under the agency’s processes, not as a result of media coverage.

Other critics addressed other aspects of the Santillan case. They asked why other doctors were not afforded to weigh in on her condition and provide a second opinion before she was deemed brain-dead.

Dr. Jaggers replied that a second pediatric neurologist from Duke hospital was recruited to confirm her death and the standards of brain death are apparent. Santillan was in a light coma but, with a patient in a deep coma, the team would have found it hard to decide whether to maintain life support.

He said the medical team pronounced Santillan dead after tests showed that her brain was not functioning at all. They also gave her family a chance to pay their final respects by using the ventilator to keep breathing for four hours.

Later, the team stopped providing her with medications as a Catholic priest prayed with the family at Santillan’s bedside and the last rites were administered. In the absence of medicine, Santillan’s heart stopped beating and the ventilator machine was shut off.

Dr. Jaggers said that, when children in a pediatric intensive care unit are very ill, the medical team are obligated to guard against infection and to protect their patient data confidentiality. The staff must focus on patients without distractions such as media coverage, he explained.

As a matter of hospital policy at Duke hospital and other medical facilities, each patient cannot have more than two visitors at a time, he said. Only the family is permitted to take a photo of a patient and no one can take or print photos of the medical team without their express consent, Dr. Jaggers said.

In practice, Dr. Jaggers said, the hospital did ask a visitor to leave Santillan’s bedside as more than two people were in her room. The medical team did specifically ask a person not to photograph Santillan but allowed the parents take photos and make them available to the media. Still, he said, a webmaster of a site was asked to remove photos of their medical staff from its pages.

Additionally, Dr. Jaggers said, as a matter of principle, the medical team never pressured the Santillan family into not saying or doing anything about the young woman’s situation. Rather, he said, the family was accorded the same level of high respect that most are by hospital staff in the face of a medical crisis.

(NOTE: As a regular feature, PharmPsych.com is offering up summaries of legal medical malpractice suits, especially in the field of pharmacy and other healthcare specialties. Each summary will detail the narrative for the suit, the reasons, outcomes, financial compensation and settlements involved. The summaries will also discuss the lessons learned by medical professionals.)

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Last updated September 2014