Duke Hospital Looking For Answers After Error In Organ Transplant
Posted February 19, 2003
DURHAM, N.C. — Duke University Hospital is making changes in its transplant process after a 17-year-old girl received a heart and lung transplant from a donor with a different blood type.
Jesica Santillan remains in critical condition Wednesday following transplant surgery on Feb. 7. She is at the top of the national transplant list for a new heart and lungs.
Doctors at Duke Hospital have stepped up life-support efforts. Santillan is now on dialysis for her failing kidneys.
"She is receiving very advanced intensive care support right now and other measures to try to fight the rejection," said Dr. William Fulkerson, chief executive officer of Duke Hospital.
Santillan suffers from a heart deformity that prevents her lungs from pumping enough oxygen into her blood. Her family moved from Mexico to Franklin County three years ago, in part, to increase the odds of their daughter getting a transplant.
After a three-year wait, Santillan received a transplant on Feb. 7 with a heart and lungs flown in from Boston.
The organs were sent with paperwork correctly listing the donor's blood type, said Sean Fitzpatrick of the New England Organ Bank, which sent the organs.
Somehow, the type-A organs were transplanted into the girl with type O-positive blood.
"Our staff in transplant believed the blood type compatibility has been confirmed, but that's obviously incorrect," Fulkerson said. "It's premature right now for me to try and tell you the exact cause of this because that investigation is ongoing."
Speaking through an interpreter, the girl's mother, Magdalena Santillan, said that the hospital called her and said they had received same blood-type organs, and that the organs had come exactly just to her daughter's measurements.
Fulkerson said in a statement Monday that a tragic error occurred.
"Our primary concern has always been for Jesica and her family. This was a tragic error, and we accept responsibility for our part. This is an especially sad situation since we intended this operation to save the life of a girl whose prognosis was grave. Jesica continues to remain at the top of the national organ donation list," Fulkerson said.
Hospital officials said such a mixup has never happened before in thousands of organ transplants.
Duke Universty Medical Center has a long history of successful surgeries. Transplants began at Duke in 1965 when the hospital became one of the first in the country to establish a kidney transplant program.
Duke also performed the first successful liver transplant in North Carolina in 1984, followed by the state's first heart transplant in 1985.
Jesica's parents said they are upset over the hospital making a mistake.
"They've been waiting for this for three long years. For it to finally happen and for the doctor to do this mistake is unforgivable." Magdalena said.
Jesica's parents said the longer she goes without a new heart and lungs, the greater the chance she will suffer paralysis or neurological damage.
Officials said the hospital will implement additional safeguards to improve the transplant process.
According to the release, the measures include multiple confirmations of donor match by members of the care team before a transplant, and improved communications between the hospital and the organ procurement organization.