Hospital officials detail errors that led to organ transplant mix-up

Following the end of Jésica Santillán's struggles, Duke Hospital's own ordeal may be just beginning.

The Hospital has been targeted with intense criticism for both its mistaken Feb. 7 transplantation of a heart and lungs of incompatible blood type into 17-year-old Jésica and for its conduct in the aftermath.

Now, the Santillán family is considering legal action, multiple health care overseers are conducting investigations and the national press is asking questions.

Family friend and spokesperson Mack Mahoney has complained of the Hospital's aggressive attempts to underplay the severity of its mistake and to keep details from the media.

In a press conference Thursday--after the second transplant, but before the revelation of serious complications--Mahoney argued that the Hospital delayed his attempts to draw media attention to Jésica, dangerously prolonging the time she spent on life support. Doctors have told the family Jésica's eventual death probably stemmed from the lengthy time she spent on life support.

"Had Duke just admitted this mistake a few days earlier, we wouldn't be facing these problems today," he said Thursday. "If she dies, [Duke] murdered her."

Acknowledging the eventual transplant was not the result of a direct donation, Mahoney explained that attention to Jésica may have encouraged open organ donations, citing as proof the quick turnaround from when the story broke nationally to the time the second set of organs became available.

Since an initial press report Feb. 17, the Hospital has repeatedly conceded its complicity in the fatal error, pointing especially to the failure of Associate Professor of Surgery Dr. James Jaggers--the surgeon for both of Jésica's transplant operations--to confirm blood type match on the first transplant.

"As Jésica's surgeon I am ultimately responsible for the team and for this error," said Jaggers in a statement Saturday, following Jésica's death. "I personally told the Santillán family about the errors that were made and then tried to do everything medically possible to treat Jésica to try to save her life."

Further details surrounding the error were provided by the Hospital in a Friday letter to the United Network for Organ Sharing, the national database that matches donated organs to potential recipients.

Late Feb. 6, Carolina Donor Services, the regional transplant office, offered the organs to Jaggers for a Duke pediatric patient, based on a UNOS match. He declined because the patient was not ready for surgery, but then inquired about the organs' availability for Jésica, identifying her by name and specifically asking about the status of the lungs. The CDS organ coordinator said he would check and call back. On the return call, the organs were offered to another Duke surgeon for an adult patient, who was rejected because of size incompatibility.

The organs were then offered to Jaggers for Jésica, presumably without a UNOS match. Jaggers recalled a discussion of height, weight and cause of death, but not blood type. He previously indicated that he assumed CDS had confirmed a blood type match before offering the organs.

The letter to UNOS admitted two errors on Jaggers's part--making the assumption of blood type match and failing later to confirm this.

However, UNOS spokesperson Anne Paschke noted that Jaggers's request for the organs represents a significant error.

"That's not policy," she said. "Organs are supposed to be cleared through our organization first." Paschke noted the error is not a common one.

A UNOS statement released Thursday said Jésica's name had never appeared on a match list for the organs, so she never should have been considered for the transplant. The organization plans to review the Hospital's letter and may demand further explanation. Neither CDS nor Hospital officials were available for comment over the weekend.

Meanwhile, the national accrediting body for hospitals has demanded a detailed report from the Hospital explaining the error, and the North Carolina Medical Board, which oversees doctors, has launched an inquiry.

An investigation of Duke Hospital by the North Carolina Division of Facility Services is also ongoing. Although DFS spokesperson Jim Jones would not discuss details of the probe, he noted two teams were sent to the Hospital Thursday, in reaction to complaints related to the initial organ transplant. One team is investigating clinical laboratory issues and the other acute care; both will ensure compliance with Medicare regulations.

The investigation will be very thorough, said Jones, noting the ensuing report would likely cover a desk several feet thick. "This stuff is not simple," he said.

Any negative results of the inquiry will be passed on to other state agencies for potential fines and federal agencies for more stringent punishments like removal of accreditation and the loss of eligibility to treat Medicare patients.

Jones would not comment on the likelihood of any of these scenarios, though. "This may be as bad as a thing can get," he said. "I don't know."


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