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Hospital's 'tragic error' led to wrong transplant

Duke University Hospital admitted a "tragic error" Monday in transplanting the heart and lungs of the wrong blood type into a 17-year-old girl now in critical condition.

Jesica Santillan, who underwent the surgery Feb. 7, is not expected to live more than a few days, said Mack Mahoney, a family friend who has medical power of attorney for the girl because her parents do not speak English.

As of early Tuesday afternoon, family friends were reporting the girl was still in declining health and getting more swollen, while doctors have told them her kidneys have stopped operating.

"In our efforts to identify organs for this desperately ill patient, regrettably, a mistake occurred," Chief Executive Officer of Duke Hospital Dr. William Fulkerson said in a statement. "This was a tragic error, and we accept responsibility for our part."

Hospital officials refused to elaborate on exactly how the type-A organs were mistakenly transplanted into the girl, who has type-O-positive blood, but Mahoney, a philanthropist who helped raise the money for the operation, claimed the family was told it was a "clerical error" that Jesica was listed as a potential recipient for the organs.

Dr. James Jaggers, associate professor of surgery, admitted to the family following the surgery that, in a rush, he did not check the organs' blood type when they reached the Hospital, Mahoney told The Herald-Sun of Durham.

Jesica's original heart was too large for her chest and impressed on her lungs, cutting off oxygen flow to the blood. Her parents moved to the United States from Mexico to find the needed organs, for which Jesica has waited three years.

The Santillan family held a press conference Tuesday afternoon in the Brookwood Inn near the Medical Center for media hailing from across the United States and Mexico, describing their initial elation at finally finding what they were told were matching organs and their ultimate disappointment.

Jesica remains at the top of the national organ donor list, and the family said they hoped a match could be found in the short time the girl has left.

According to a statement issued by Mahoney, Hospital administrators tried to stop the family from speaking to the press or taking pictures of Jesica, and attempted, in a "hostile" meeting with the family and Mahoney, to limit the latter's access to the girl, against the wishes of her parents.

The Hospital's tone changed when Sen. Elizabeth Dole, R-N.C., Woman's College '58, called the cellular phone of Mahoney--her Franklin County campaign manager--during the meeting. Dole offered to speak with one of the administrators, who declined, according to Mahoney's statement.

"The Hospital's tone instantly changed the minute Mack hung up the phone with Senator Dole," the statement reads.

Medical Center officials declined to comment on Mahoney's claims. A Dole spokesperson could not be reached for comment.

The New England Organ Bank, which sent the organs, confirmed Monday that the donor's organs were clearly and correctly labeled before leaving Boston.

Based on a match found in the national organ database maintained by the United Network for Organ Sharing, NEOB conveyed an organ "import offer" to the regional transplant office, Carolina Donor Services, said CDS spokesperson Jane Corrado.

"In this case, the organs were then offered to Duke and [Duke was] relayed the info we got from New England," she said. "From that point on, it's the Duke surgeons' decision to transplant."

In a CDS statement late Tuesday, Corrado elaborated that the offer was originally made for two type-A-positive patients cleared through UNOS, but after these were declined by Duke transplant surgeons, one of the surgeons requested the heart and lungs for a third patient, Jesica Santillan. "Carolina Donor Services was informed that Duke suspected an incompatible blood match only after the transplant took place," she wrote.

To UNOS officials' knowledge, only twice before in the last 15 years has an organ with the incorrect blood type been delivered to a recipient, and only once was such an operation completed--the patient died soon afterward.

UNOS's database checks for blood type match, indicating the initial error must have been made somewhere else, spokesperson Anne Paschke said. "There are a number of different error points. It could be incorrectly entered into the system; there's the whole process of packaging," she said.

Paschke noted UNOS does not plan to alter any of its methods as a result of the SantillA¡n case. "I think you'll get people working on the processes, but not on the computer matching," she said.

Duke Hospital is already working on improving its procedures for organ transplantations, Fulkerson indicated in his Monday statement. "We are taking immediate steps to further strengthen those processes within our control here at Duke and will work to identify ways to improve the entire organ procurement process," he said.

Among the changes, he noted requirements of multiple confirmations of donor match and improved communication with the organ procurement organization.

In total, Duke has performed more than 20 dual heart-lung transplants since 1992, in addition to 375 heart transplants and 400 lung transplants, one of the highest totals in the country.


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