The recent tragic death of 17-year-old Jessica Santillan at Duke Hospital sent shock waves to transplant communities throughout the country. Jessica died after receiving a heart and lungs from a donor with the wrong blood type. Santillan’s surgeon James Jaggers, M.D. claimed responsibility for the tragic human error.
Andrew Klein, M.D., director of the Johns Hopkins CTC and a member of the UNOS board, believes valuable lessons emerged from the tragedy: “Although we have always been vigilant about checking blood types before surgery, now we are increasing our safeguards.”
“My opinion is that an unfortunate confluence of events contributed to the tragedy at Duke. At Hopkins there is considerable redundancy within our system to prevent such an occurrence,” he said.
Klein added that after the local procurement organization in this region and the hospital have confirmed compatibility, the surgeon, nursing team and anesthesiologist must sign off on the match: “In our hospital, we will not go into the operating room until all the team members agree that the organ is appropriate for the intended recipient.”
Surgeon David Yuh, M.D., of the Hopkins Cardiac and Lung Transplant Service, noted: We will continue to check every detail during all transplants. A specific example of these efforts is the institution of a Donor Confirmation Data Sheet, which will require documenting all information about a thoracic organ donor, including blood type, by the procurement team.”
