Duke Admits Transplant Error
Heart-Lung Donor's Blood Type Didn't Match Young Recipient'sFeb 18, 2003 | Raleigh News
Officials at Duke University Medical Center accepted responsibility Monday for a "tragic error" that occurred when their doctors transplanted a heart and lungs into a teenage girl whose blood type didn't match the donor's.
Exactly what caused the error, however, has not been disclosed. Dr. William Fulkerson, chief executive officer of Duke Hospital, said officials are continuing their investigation of the events that led to the ill-fated transplant on 17-year-old Jesica Santillan.
The girl, who moved to the United States from Mexico three years ago to seek treatment for a fatal heart condition, is clinging to life. She can be saved only with another heart-lung transplant, but the prospects of finding new organs are slim.
"This was a tragic error, and we accept our responsibility," Fulkerson said in a statement. "This is an especially sad situation, since we intended this operation to save the life of a girl."
In an interview, Fulkerson said Duke officials have established new safeguards to ensure that such a mismatch could never occur again. Additional staff members have been designated to triple-check the compatibility of organs before transplant.
But it remains unclear how organs from a person in New England with Type A blood were sent to Durham to be transplanted into Jesica, who has Type O blood. The incompatibility defies a system that has been established to avoid such mistakes.
"Our belief was that the blood compatibility had been confirmed when the organs came," Fulkerson said. "We're looking at that process and at that communication to try, again, to clarify all the steps in the process."
In typical cases, people who need transplants are put on a computer registry maintained by the United Network for Organ Sharing. The registry includes the blood type, age, geographic location and other information of recipients. Similarly, when organs become available, the donor information is keyed into the registry.
The UNOS computer system then searches the database to pinpoint potential matches, and blood type is the most critical criterion.
Once a match is suggested, the recipient's surgeon is called and offered the organs. Based on all the recipient's medical considerations, the surgeon can accept the organs or decline them. If the surgeon declines, the organs are offered to the next person on the list.
Officials at the New England Organ Bank, which procured the heart and lungs transplanted into Jesica, said their records indicate that the donor's Type A blood was clearly presented along every step of the process.
"We have gone through our files, and the most important thing is that the donor's blood type was on there it accompanied the organs to [North] Carolina," said Sean Fitzpatrick, director of public education for the New England Organ Bank. "The information had been sent down previous to the organs arriving."
Fulkerson said Duke's new system will "ensure that all parties have accurate information about the blood type compatibility of donated organs."
The hospital's admission of its mistake is a comfort, said Mack Mahoney, a builder from Louisburg who has helped Jesica's family since reading about her illness in his local newspaper. He has been battling hospital officials since last week, he said, angering them by going public with Jesica's plight in the hopes of inspiring another organ donation.
"I think it's good they've admitted it," Mahoney said, "but we still have a sweet little girl who did not deserve what she got."
He said Jesica has not been conscious since Wednesday and suffered a seizure Sunday. Powerful immune-suppressant drugs are staving off organ rejection, but it's a losing proposition when the blood types don't match.
Her only hope is another transplant. Jesica is first on a list of about 200 patients in the United States awaiting the organs. But only 28 heart-lung transplants were performed last year.