Statement From Duke's Chancellor For Health Affairs
Posted February 26, 2003
DURHAM, N.C. — The following is a message from Ralph Snyderman, M.D., Chancellor for Health Affairs at Duke University, President and CEO of Duke University Health System, distributed Feb. 24, 2003, to DUHS staff regarding Jesica Santillan.
"I have never been more proud to be a part of the Duke University Medical Center family than I am right now. This statement may seem strange at a time when our institution is under such duress and international scrutiny because of a tragic event surrounding a patient who was in our care.
"The treatment of Jesica Santillan demonstrates the strengths and weaknesses of our nation's healthcare system. An impoverished individual from a foreign country who would certainly have died of a fatal heart disease came to Duke to benefit from a surgical procedure that requires technology at least as complicated as that needed to send a human to the moon and back.
"The surgical procedure was performed with technical excellence second to none. But, tragically, her organs were rejected due to a blood type mismatch. The tragic outcome of this heroic procedure was the result of human errors and an insufficient backup system.
"The response to the tragedy, however, was a true test of our institution. When the surgeon, Dr. Jim Jaggers, understood the problem of the mismatch, he immediately assumed responsibility for his role, informed the family and placed the patient on the priority list for a second heart-lung transplant. He signaled the problem to the institution, which immediately initiated a sentinel review process and instituted corrective actions to prevent such mishaps in the future.
"The nature of the error and the international press attention has put our institution under the magnifying glass by the outside world as never before. In my view, the institution has been open, honest and forthright. It immediately focused on determining the root cause of the error and in treating the patient and the family in the most appropriate and compassionate way.
"This unfortunate situation will spur us to review even more carefully all issues concerning patient safety and medical errors, a national problem, as recognized by the Institute of Medicine. Our institution has focused tremendous energy on implementing systems and attention by all our staff on ensuring patient safety and preventing medical errors.
"Our overall record is outstanding. Nonetheless, this is an important national concern and must be addressed with vigor.
"I am so proud of this institution because of the excellence of the people within it, their response to adversity and their commitment to always achieving perfection wherever possible. We are all human, with human strengths and weaknesses. It is when weaknesses are manifested that the importance of community becomes greater than ever.
"The strength of our people in coming together, their commitment to our own standards of excellence, and their support for our patients, their families and for each other are what makes me so proud to be a member of this team.
"You can be certain we will always continue to strive to be the very best that we can and to continue to learn and improve. I will be forever grateful to the many of you who have risen even higher than before in the treatment of Jesica Santillan and the response to the events surrounding her care.
"We will never forget Jesica or her family. Their loss is our loss, and we commit that her memory will serve as a strong ongoing force to further strengthen systems that ensure patient safety at Duke and throughout our nation."