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Death of transplant recipient due to blood type mix-up continues to resonate in transplant community, media.

The death of Jesica Santillan 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 "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 Organ Bank (NEOB) in Boston.

In an interview with Ed Bradley, James Jaggers, MD, the Duke pediatric 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, off bypass," Jaggers told Bradley. "And we were planning to get ready to close the chest and move up to the 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 problem could have been prevented if UNOS, 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 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 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.
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Comment:Death of transplant recipient due to blood type mix-up continues to resonate in transplant community, media.
Publication:Transplant News
Geographic Code:1USA
Date:Mar 31, 2003
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