State Report Reveals 'Serious' Flaws At Duke University Hospital
Posted March 28, 2003
DURHAM, N.C. — In a 54-page report, inspectors revealed some serious flaws at Duke University Hospital.
An investigation was launched after Jesica Santillan received a heart and lung transplant of the wrong blood type. She died after a second transplant.
The report was released Wednesday by the
Centers For Medicare and Medicaid Services
Santillan's doctor, Dr. James Jaggers, took responsibility for the transplant mistake. But inspectors found other problems, as well.
Instead of getting combative over the findings, Duke leaders are cooperating.
"There's some things we need to improve," Duke Hospital CEO Williams Fulkerson said.
Fulkerson does not refute many of the deficiencies identified in the report.
Mistakes in Jesica's transplant were made from the very beginning. The report states two surgeons failed to confirm the blood type of the donor and recipient organs prior to the flight to the donor facility.
The report states the facility failed to provide medical leadership in transplant surgical services that would ensure a consistent and patient-safe solid organ transplant program.
Failure to correct the problems could result in Duke losing critical federal funding.
"I suspect in a worst case scenario, it could affect our ability to care for patients," Fulkerson said. "But that will not happen."
When the organs arrived at Duke, the report states the blood type of the donor patient was clearly marked on the cooler, on the front of the donor packet and on the first page of the donor packet.
Overall, inspectors found the pediatric surgical transplant services and nursing services were not well organized and were not provided in accordance with acceptable standards of practice.
The team of inspectors found deficiencies in five areas of the hospital: surgical services, nursing services, governing body, medical staff and quality assurance.
The health agency that ordered the inspection calls the findings "serious" and said that it does not happen often.
A Duke spokesman said the hospital has come up with a plan to correct the problems. He said many have already been taken care of the rest will be corrected next month.
The Santillan family attorney, Kurt Dixon, said that if Jesica's family decides to sue, the report should be admissible in court.
"We have a very good idea that numerous places in the chain had broken down," Dixon said, "and it wasn't just Dr. Jaggers who failed to check the blood type.
This investigation is not over. Division of Facility Services investigators are back this week, looking at operations throughout the entire hospital.
The state is also monitoring the hospital until all of the problems are fixed.
"Whatever issues that they find, we will change them if we need to to come into compliance," Fulkerson said. "If we should not come into compliance, we will change them, and I guarantee you; we'll be in compliance."
Fulkerson said he hopes the changes Duke is making in its system will serve as a national model to improve the transplant system.