Death of transplant recipient due to blood type mix-up continues to resonate in transplant community, media.
The death of Jesica Santillan Jesica Santillan (December 26, 1985 - February 22, 2003) was an illegal immigrant from Mexico who entered the United States to obtain medical treatment, but died after an organ transplant operation in which she received the heart and lungs of a patient whose blood type did not due to a blood type mismatch at Duke University Medical Center continued to resonate in the media during March.
For example, on March 16 CBS (Cell Broadcast Service) See cell broadcast. "60 Minutes" aired a segment entitled "Anatomy of a Mistake" featuring interviews with representatives from Duke and Carolina Donor Services (CDS), the local organ procurement organization (OPO) that delivered the organs to the hospital for transplantation. The organs were recovered by the New England New England, name applied to the region comprising six states of the NE United States—Maine, New Hampshire, Vermont, Massachusetts, Rhode Island, and Connecticut. The region is thought to have been so named by Capt. Organ Bank organ bank Transplant medicine A repository, usually shared by multiple hospitals for long-term storage of certain tissues destined for transplantation–eg, acellular bone fragments, BM, corneas. Cf UNOS. (NEOB NEOB New England Organ Bank
NEOB New Executive Office Building (Washington, DC) ) in Boston.
In an interview with Ed Bradley, James Jaggers, MD, the Duke pediatric pediatric /pe·di·at·ric/ (pe?de-at´rik) pertaining to the health of children.
Of or relating to pediatrics. transplant surgeon who performed the transplant, explained the blood type mismatch (Jesica was type O, the donor was type A), wasn't discovered until the operation had been underway for 5 hours.
"We had already put in the new organs and we had actually come off the heart-lung machine heart-lung machine, device that maintains the circulation of the blood and the oxygen content of the body when connected with the arteriovenous system; it is also called the pump oxygenator. , off bypass," Jaggers told Bradley. "And we were planning to get ready to close the chest and move up to the ICU ICU intensive care unit.
intensive care unit
see intensive care unit.
ICU . And it was about that point, about an hour, an hour and 15 minutes after we had put the organs in, that we got the call that this was an incompatible transplant. And we, of course, knew what that meant at that point."
Jaggers took full responsibility for the error. "I'm ultimately responsible for this because I'm Jesica's doctor and I'm arranging this," he told Bradley. "But honestly, I look back, and yeah, if I'd made one more phone call or if I had told somebody else to make a phone call or done something different, maybe it would have turned out differently. But you know, those are all 20/20 hindsight."
The segment also hinted that the blood typing blood typing
Classification of blood by inherited antigens associated with erythrocytes (red blood cells). The ABO blood-group system and Rh blood-group system are among those most commonly considered. problem could have been prevented if UNOS UNOS United Network for Organ Sharing Transplant surgery A database dedicated to optimizing the use of transplantable organs; according to UNOS statistics–1995, ± 20,000 major organs and tissues are transplanted/yr; since successful survival of , CDS and NEOB had better policies in place. The program said Jordan Lloyd Jordan, CDS executive director, admitted they did not ensure there was a match. "We could have requested her blood type, and I wish we had, but we did not do that," Jordan told Bradley.
Following the broadcast, CDS was compelled to issue a statement adamantly denying it had failed to adequately check the donor's blood type as alleged in the segment.
"CDS' role was to effectively and correctly communicate the donor's blood type and other pertinent medical information from the host organ procurement organization (OPO), New England Organ Bank (NEOB), to Duke Medical Center (Duke), which was done accurately and completely.
CDS was not the host OPO; therefore we could not and did not release the organs. CDS received a call from NEOB, the host OPO, offering Type A organs to two donor match run list patients at Duke. We then conveyed the offer along with the donor information including blood type, to Dr. James Jaggers at Duke. Dr. Jaggers declined the offer for his patient who was blood type compatible with the donor. Dr. Jaggers then communicated his desire to use the organs for Jesica Santillan.
CDS communicated Jesica Santillan's name and unique UNOS identification number to NEOB, which was the only agency in possession of the donor match run list. NEOB subsequently asked CDS to convey its offer to Duke, which CDS did, and Duke accepted.
CDS was the information conduit between NEOB and Duke. As we shared with "60 Minutes," CDS conveyed the donor's blood type and other pertinent medical data to Duke on six different occasions, a redundancy of four times before the transplant and two subsequent times.
*First, CDS communicated the blood type of the donor on the phone to Dr. Jaggers.
*Secondly, CDS provided the blood type of the donor to the Duke recovery surgeon on the plane.
*CDS also confirmed the blood type of the donor upon entering the operating room operating room
n. Abbr. OR
A room equipped for performing surgical operations. with the Duke recovery surgeon. This is our standard practice, in order to ensure information we have received over the phone from the host OPO and conveyed to the transplant center is accurate and matches the donor records at the donor hospital.
*Prior to leaving the donor hospital operating room, CDS also properly labeled the blood type of the donor organs on a tag attached to organ packaging.
*CDS hand delivered a form with the donor blood type to the HLA HLA human leukocyte antigens.
human leukocyte antigen
HLA (human leuckocyte antigen) lab at Duke.
*Finally, CDS faxed information, including the donor blood type, to Duke's transplant coordinator."
The OPTN/UNOS is conducting an extensive investigation on the circumstances that led to Jesica's death. A full report is to be presented during the organization's board meeting in June.