Year later, meaning of Santillán case still debated

One year ago this past Saturday, Jésica Santillán died at Duke University Hospital after a second heart-lung transplant that was intended to correct an initial organ transplantation incompatible with her blood type. Although investigations ultimately determined that a failure to communicate basic information between more than a dozen people across multiple organizations was responsible for the Santillán incident, members of the medical community continue to reflect on the events surrounding her death.

A major point of contention for DUH was the role of the media in publicizing the Santillán story, in which the credibility of the hospital and Dr. James Jaggers, the surgeon who performed the transplants, was severely damaged.

"[The Santillán case] is just made for the media," said Frank Sloan, director of the Center for Health Policy, Law and Management, J. Alexander McMahon professor of health policy and management, and professor of economics. "Here was a young, vulnerable person at this very powerful establishment, and there was a mistake."

The aggressive media coverage of the Santillán case led the public to believe that medical errors are a rarity, medical student James Langheier said. "The tone of the media distracted the public. People think this never happens anywhere, but the number of medical errors actually made is absurd," he said.

The media, combined with the Santillán family's "colorful" spokesperson Mack Mahoney, who Sloan said fed the media the Santillán situation as a "real, live human-interest piece," made DUH the poster child for medical irresponsibility.

"If it had not been Duke, there would have been less attention," Sloan said. "If it were someone who was 80 years old, the news wouldn't have covered it. The irony is that medical errors happen all the time. And while [the Santillán situation] was happening, there could have been more errors elsewhere for the media to report."

In addition to the media, others involved in the situation highlighted the role Jaggers played in the Santillán case and emphasized that he should be blamed for the mistake. In an interview on the television show "60 Minutes" following Santillán's death, Associate Professor of thoracic surgery Dr. Duane Davis identified his colleague as the source of the transplantation problems. "The initial mistake," he said, "was made by Dr. Jaggers."

Carolina Donor Services, the intermediary organization that procured the organs for DUH, also implied in a press release that Jaggers was to blame for the blood-type confusion.

"Prior to Jésica Santillán, Duke surgeons have never offered a specific patient's name that was blood-type incompatible," the CDS statement said. "Duke surgeons have confirmed it is their responsibility to know the blood type of patients within their care."

Colleagues described Jaggers as one of the best transplant surgeons in the country and hoped his ability to work had not been set back. Jaggers, however, has maintained a positive outlook and views the Santillán case as a learning experience for both himself and the institution.

"This is not the only error I have ever made, nor will it be my last," Jaggers said. "We can hope for a better system, but nothing is fool-proof."

Langheier said Jaggers has been very honorable about accepting the blame for the mistake, but checking patients' blood type was not entirely his responsibility. "The surgeon is supposed to trust his team and the organ donor profiling. It's not his role to double-check for a blood type," he said.

Victor Vidal, author of 101 Ways to Prevent Medical Errors and chair of the National Campaign to Prevent Medical Errors, said in cases of medical errors, the blame lies on health care institutions rather than individual doctors, noting it was DUH's fault for administering improper care. "You cannot hold this one person accountable for the cascade of systemic failures that occurred in the Santillán case," Vidal said.

Mahoney also said Jaggers made a mistake, but he is more concerned with how DUH handled the situation.

"I never trashed Duke in the media until after the second surgery," Mahoney said. "There are things that I can't say about the second surgery because of legal reasons.... There's a lot about those second organs that are not known and I can't tell. But in my opinion, Duke as a corporation made a lot of bad choices and they didn't have to do that. All I wanted was their help.

"I don't have anything against Dr. Jaggers," Mahoney added. "Jaggers' skills were never called into question. Dr. Jaggers made a mistake--people do that."

Angela Holder, professor of practice at the Center for Ethics and Humanities, said although doctors make mistakes, patient safety is not primarily the responsibility of the doctor, but of the institution. "He did not mess up all by himself," Holder said, referring to Jaggers. "And I think that one of the worst things that happened was what was said about him.... Was it the doctor's fault? No way!"

Sloan said one positive aspect of the media attention surrounding the Santillán case was that the publicity caused the medical community to redouble its efforts on improving patient safety. Additional safeguards have since been added by the United Network for Organ Sharing and by local organ procurement agencies.

"The entire medical community has a much greater focus on patient safety. Hopefully, this is not at the expense of being afraid of doing what is best for the patient, even if there is a risk," Davis said.

"Duke Hospital remains a premier institution for health care delivery and research. It is a safer place because of the events that transpired around the Santillán transplant."