Girl Near Death After Hospital's Transplant MistakeFeb 19, 2003 | The Boston Globe The heart and lungs from a New England organ donor were supposed to save Jesica Santillan's life. Instead, they left the 17-year-old near death.
In an error that is rare but not unheard of, surgeons at Duke University Hospital implanted the organs even though the donor's blood type, A-negative, did not match Jesica's, O-positive. After the transplant Feb. 7, her body's natural defenses mounted a massive attack on the new organs. Without a new transplant, family and friends say, Jesica is not expected to live more than a few days.
For Jesica and her family, who moved from Mexico to North Carolina for the operation, joy that the three-year wait for organs was over quickly turned to shock and confusion, said Renee McCormick, a spokeswoman for Jesica's Hope Chest, a non-profit group founded by a North Carolina homebuilder to raise money for the teenager's care.
"It's hard for us to believe that a transplant surgical team can't read the (blood) type of (the) organ they have received," McCormick said. She said that Jesica's parents, Magdalena and Melecio Santillan are "as broken as broken can be."
Hospital officials acknowledged the mistake. They said they are still investigating exactly how it happened and have bolstered procedures for checking organ compatibility.
"This was a tragic error, and we accept responsibility for our part," said Dr. William Fulkerson, the hospital's chief executive. "This is an especially sad situation since we intended this operation to save the life of a girl whose prognosis was grave."
According to Jesica's Hope Chest founder Mack Mahoney, who has legal rights to participate in Jesica's medical decisions, the girl's surgeon told her family and Mahoney that he was in such a rush to implant the organs that he did not check the blood type. The organs stay viable for only four to six hours.
Hospital officials said the surgeon, Dr. James Jaggers, was not available to comment, but spokesman Richard Puff said, "We believed the blood type compatibility had been confirmed, but that was incorrect."
Jesica had a heart deformity that prevented her lungs from pumping enough oxygen to her blood. Without the transplant, Mahoney said, she would have died within six months. She remains on a waiting list for new organs, but has suffered a heart attack and is being kept alive by machines, according to Mahoney.
While much is still unclear, the incident has the organ-donation community reeling and perplexed. The New England Organ Bank, which coordinated the donation, says it properly identified the donor's blood type and made it clear to a group of Duke surgeons who flew to Boston to recover the organs.
Organ-donation rules require that blood types be clearly labeled on organ containers. Under normal surgical procedures, Jesica's blood type should have been checked one more time before surgery as the hospital's internal blood bank prepared extra blood for transfusions, said Dr. James Pomposelli, a liver transplant surgeon at the Lahey Clinic.
The mix-up is the type of maddeningly simple error, like medication dosage errors or wrong-side surgery, that has gained increasing public attention after the 1999 Institute of Medicine report that found more than 90,000 Americans a year die from medical mistakes.
The United Network for Organ Sharing does not formally track organ blood-type mix-ups, but officials said they could recall only two previous incidents.
However, newspapers reported three such mix-ups in the early 1990s. In 1990, a 47-year-old man died after getting a heart with the wrong blood type at Abbott Northwestern Hospital in Minneapolis.
In 1991, surgeons at Oregon Health Sciences University in Portland transplanted a heart with the wrong blood type into a man, who received a different heart four days later and survived. Three years later, at the same hospital, a similar mistake was caught before transplant, but without a happy ending. Surgeons opened a 15-year-old boy's chest, realized the new heart was the wrong type, and stopped the operation. But no new heart was fund and the boy died 10 days later from his original condition.
The hardest part of Jesica's case, said Anne Paschke, a spokeswoman for United Network for Organ Sharing, is that the day an organ is found is supposed to be a happy one.