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From The NYT 18Feb03
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Girl, 17, Fights for Life After Organ-Donor Error
By DENISE GRADY
A 17-year-old girl is in critical condition after mistakenly being given a heart and lung transplant from a donor with the wrong blood type at Duke University Hospital in Durham, N.C.
The patient, Jésica Santillán, has rejected the organs and is unconscious and on life support. Doctors say she is unlikely to survive more than a few days without another transplant. But she has little chance of getting one, because donors are scarce. In 2001, doctors performed only 27 heart-lung transplants in the United States.
Her family's last hope is that a dying patient who is a suitable Type O donor can be found, and that that person's family will make a "directed donation" to Ms. Santillán.
Duke issued a statement on Monday accepting responsibility for its part in the mistake, which happened on Feb. 7, but did not explain how it occurred.
The donor had Type A blood, and Ms. Santillán Type O. People with Type O blood can safely receive transfusions or organ transplants only from others who are also Type O; mismatches can be fatal.
Dr. William Fulkerson, the hospital's chief executive officer, said he could not discuss how the error was made until the hospital completed its own investigation, possibly within a few days.
"We've done thousands of transplants here over 30-plus years," Dr. Fulkerson said. "This has never happened. It's a unique tragedy for us."
He said that Duke had already changed its procedures to require that three members of the transplant team check the medical records of organ donors and recipients before surgery to make sure that they were compatible. Until now, he said, only the transplant surgeon was required to check.
Ms. Santillán's family moved from Mexico to North Carolina three years ago in hopes that she would be treated at Duke for a condition called restrictive cardiomyopathy, which caused an enlarged, weakened heart and damaged lungs. She had suffered from the problem for most of her life and was deteriorating.
By Feb. 7, when a heart and lungs became available, doctors estimated that Ms. Santillán would survive only about six months without a transplant.
Two groups involved in the transplant have provided clues to how the mistake may have occurred.
According to Carolina Donor Services, on Feb. 7, the New England Organ Bank said it had a heart and lungs from a Type A donor who, according to a national database, matched two Type A patients at Duke. The Carolina group notified Duke, but surgeons there declined the organs, because for reasons other than blood type they were not suitable for the two patients listed in the database. However, one of the Duke surgeons, whose name was not revealed by the Carolina group, requested the heart and lungs for a third patient.
The third patient was Ms. Santillán, who has Type O blood.
The New England Organ Bank issued a statement saying it had correctly identified the donor as Type A and had given the information to Duke twice, before the organs were removed from the donor and again when Duke surgeons arrived in New England to perform the surgery to remove them. The bank would not say where this surgery occurred.
As the surgeons flew back to North Carolina with the heart and lungs, Ms. Santillán's transplant surgeon began removing her organs. Time was short because heart-lung combinations deteriorate quickly, and doctors wanted to implant the new organs as soon as they arrived at Duke.
The operation went smoothly until routine tests performed near its completion revealed that Ms. Santillán and the organ donor did not have matching blood types and that Ms. Santillán was already beginning to reject the organs, Dr. Fulkerson said.
Mack Mahoney, a spokesman for Ms. Santillán's family, said that her surgeon, Dr. James Jaggers, told the family about the mistake immediately after the surgery, and listed Ms. Santillán for another transplant. He also said medicines might control the rejection, Mr. Mahoney said. They did not.
__________________________________
Girl, 17, Fights for Life After Organ-Donor Error
By DENISE GRADY
A 17-year-old girl is in critical condition after mistakenly being given a heart and lung transplant from a donor with the wrong blood type at Duke University Hospital in Durham, N.C.
The patient, Jésica Santillán, has rejected the organs and is unconscious and on life support. Doctors say she is unlikely to survive more than a few days without another transplant. But she has little chance of getting one, because donors are scarce. In 2001, doctors performed only 27 heart-lung transplants in the United States.
Her family's last hope is that a dying patient who is a suitable Type O donor can be found, and that that person's family will make a "directed donation" to Ms. Santillán.
Duke issued a statement on Monday accepting responsibility for its part in the mistake, which happened on Feb. 7, but did not explain how it occurred.
The donor had Type A blood, and Ms. Santillán Type O. People with Type O blood can safely receive transfusions or organ transplants only from others who are also Type O; mismatches can be fatal.
Dr. William Fulkerson, the hospital's chief executive officer, said he could not discuss how the error was made until the hospital completed its own investigation, possibly within a few days.
"We've done thousands of transplants here over 30-plus years," Dr. Fulkerson said. "This has never happened. It's a unique tragedy for us."
He said that Duke had already changed its procedures to require that three members of the transplant team check the medical records of organ donors and recipients before surgery to make sure that they were compatible. Until now, he said, only the transplant surgeon was required to check.
Ms. Santillán's family moved from Mexico to North Carolina three years ago in hopes that she would be treated at Duke for a condition called restrictive cardiomyopathy, which caused an enlarged, weakened heart and damaged lungs. She had suffered from the problem for most of her life and was deteriorating.
By Feb. 7, when a heart and lungs became available, doctors estimated that Ms. Santillán would survive only about six months without a transplant.
Two groups involved in the transplant have provided clues to how the mistake may have occurred.
According to Carolina Donor Services, on Feb. 7, the New England Organ Bank said it had a heart and lungs from a Type A donor who, according to a national database, matched two Type A patients at Duke. The Carolina group notified Duke, but surgeons there declined the organs, because for reasons other than blood type they were not suitable for the two patients listed in the database. However, one of the Duke surgeons, whose name was not revealed by the Carolina group, requested the heart and lungs for a third patient.
The third patient was Ms. Santillán, who has Type O blood.
The New England Organ Bank issued a statement saying it had correctly identified the donor as Type A and had given the information to Duke twice, before the organs were removed from the donor and again when Duke surgeons arrived in New England to perform the surgery to remove them. The bank would not say where this surgery occurred.
As the surgeons flew back to North Carolina with the heart and lungs, Ms. Santillán's transplant surgeon began removing her organs. Time was short because heart-lung combinations deteriorate quickly, and doctors wanted to implant the new organs as soon as they arrived at Duke.
The operation went smoothly until routine tests performed near its completion revealed that Ms. Santillán and the organ donor did not have matching blood types and that Ms. Santillán was already beginning to reject the organs, Dr. Fulkerson said.
Mack Mahoney, a spokesman for Ms. Santillán's family, said that her surgeon, Dr. James Jaggers, told the family about the mistake immediately after the surgery, and listed Ms. Santillán for another transplant. He also said medicines might control the rejection, Mr. Mahoney said. They did not.
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