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Hospital attempts to solve problems

Duke Hospital officials are confident that they can fix the problems listed in recent critical reports by two health care overseers before the advent of serious consequences.

In an investigation stemming from the fatal Feb. 7 transplant of a heart and lungs of incorrect blood type into Jésica Santillán, the federal Center for Medicare and Medicaid Services issued a 54-page document of 50 problems with Hospital procedure last Wednesday, effectively threatening the Hospital's right to receive compensation for treating Medicare and Medicaid patients.

For the same reason, the national accrediting body for health care institutions - the Joint Commission on Accreditation of Health Care Organizations - issued a similar report that resulted in a downgraded accreditation status for the Hospital.

Spokesperson Richard Puff said the Hospital has issued a "plan of action" to both organizations and is working aggressively to fix the problems. "We are working very closely with them and cooperating fully," he said. "We will come into compliance and will do whatever is necessary."

With Hospital administrators accustomed to Duke's lofty rankings among the best hospitals in the country, the lowered accreditation status came as a hard hit. "Certainly we don't like seeing our accreditation downgraded in any way, and we certainly expect it to be returned when we come into compliance," Puff said.

Both reports questioned the qualifications of the pediatric transplant coordinator and the surgeon who procured the donated organs Feb. 7. The two were properly trained, said Puff, although adequate documentation was mistakenly not included in the transplant coordinator's file.

Communication among the Hospital, the regional transplant office and the national organ database was also questioned in both reviews. Puff said the three organizations are currently planning how to improve cooperation.

Following the initial investigation documenting the problems, the Center for Medicare and Medicaid Services initiated a thorough review of the Hospital, which will be completed today.

The plan of action sent last week to both organizations builds on changes to Hospital regulations enacted soon after the Santillán transplant, noted Director of Accreditation and Regulatory Affairs Gail Shulby in a March 21 statement.

"As a result of our own internal review, many changes were immediately made," she wrote.

Among changes already enacted, multiple confirmations of blood type match were instituted in the transplant procedure, and the adult and pediatric transplant programs were merged.

Since the botched transplant, many top-level administrators within the Medical Center and the Hospital have expressed determination that Santillán's example would transform Duke into a role model for patient safety.


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