Faculty Bibliography

Medical errors are thought to be responsible for as many as 98,000 deaths in the United States every year, and the nation's most august hospitals are far from immune. The errors have often resulted, as in Duke's case, not from a failure of cutting-edge medicine but from lapses in the most basic safety procedures. In 1999, the Institute of Medicine of the National Academy of Sciences reported that medical errors kill 44,000 to 98,000 people a year and that many of these deaths could be prevented by improving safety measures. Most medical errors do not result from individual recklessness, but from basic flaws in the way hospitals and clinics operate, the report said

After reviewing Ms. [Jesica Santillan], Duke officials began requiring three members of the transplant team to verbally communicate the results of the tests of the donor's and recipient's blood types, which are important in determining compatibility. Duke had not required it before. ''We believe that the changes we have put in place enhance the safety of the procurement process and should be considered as a national guideline,'' said Dr. William J. Fulkerson, vice president and chief executive of Duke University Hospital, and Dr. R. Duane Davis, surgical director of Duke's transplant program. Others believe that such changes should be determined by independent panels, not the hospitals that make the errors. Ms. Santillan's case ''is an unfortunate but pertinent illustration of the fact that these kinds of errors in complex situations are systematic errors,'' said Dr. Joseph J. Fins, an internist and the director of medical ethics at New York Hospital-Cornell Medical Center, ''and we need to devote as much money to the prevention of error and understanding of the systems that can engender error as we do to the understanding of the immunology of transplantation.''

Medical errors are thought to be responsible for as many as 98,000 deaths in the United States every year, and the nation's most august hospitals are far from immune. The errors have often resulted, as in Duke's case, not from a failure of cutting-edge medicine but from lapses in the most basic safety procedures. Of course, elite hospitals are not the only places where such errors occur. But serious mistakes at such institutions are particularly shocking because the hospitals are role models. They have earned their reputations because of their staffs' knowledge, technical skills and ability to develop and apply the newest and best therapies. In 1999, the Institute of Medicine of the National Academy of Sciences reported that medical errors kill 44,000 to 98,000 people a year and that many of these deaths could be prevented by improving safety measures. Most medical errors do not result from individual recklessness, but from basic flaws in the way hospitals and clinics operate, the report said

The doctors have discussed the findings with her family, the officials said, without adding further comment. Additional studies to assess brain function are under way and we continue to do everything we can to support her, the hospital said. On Feb. 7, after a three-year wait, [Jesica Santillan] received a heart and two lungs from a donor with an incompatible blood type. Duke officials have said they accept responsibility for the error, but they have not publicly disclosed precisely what went wrong. Jesica has blood group O; the first donor was type A. Right after her second transplant surgery, Dr. Duane Davis, surgical director of the lung transplant program at Duke, told reporters that she had not suffered any irreversible damage

It is a long shot for her to recover, said Dr. Robert Robbins, of the Heart-Lung and Lung Transplantation Program at Stanford University. Unlike [Jesica Santillan], most patients who receive second heart transplants do so because their immune systems reject the donor organs. Because the heart and lungs Jesica received came from a person with a mismatched blood type, her body mounted a furious attack on the mismatched organs. The blood type incompatibility is generally more serious in transplanting lungs because lung tissue has a propensity to react very strongly immunologically, the doctors said. Dr. Mehmet Oz, a heart surgeon at New York-Presbyterian Hospital, said that if Jesica survived, her chances for serious long- term medical problems like infection and immunological disorders would be about 80 percent. Still, Jesica's parents, who are from Mexico, celebrated that their daughter had been given a second chance when new organs from a donor with matching type O blood were found Wednesday. Outside the hospital here in Durham, Jesica's parents hugged in front of a growing crowd of reporters. The couple looked exhausted. We are blessed, her mother, Magdalena, said

Once the organs arrived, Ms. [Jesica Santillan]'s heart and lungs were removed and the donor organs were implanted. Ms. Santillan was removed from the heart-lung bypass machine and the organs functioned well for 30 or 40 minutes. They began to fail and Ms. Santillan was returned to the machine. Moments later, the operating room heard the worst possible news from the transplant immunology laboratory: ''the transplant was ABO incompatible with the recipient.'' Ms. Santillan's condition was stabilized and she was moved to the pediatric intensive care unit. Because the designated recipient's condition was not suitable for transplant surgery, Dr. [James Jaggers] asked about the availability of a heart and lungs for Ms. Santillan as well as the status of the donor's lungs. The coordinator offered the heart and lungs to Dr. [R. Duane Davis] for an adult patient. Dr. Davis declined because the organs were incompatible in size for an adult

The growing Latino community in this area seems especially moved. The new Mexican Consulate in nearby Raleigh is working to connect the Santillans with relatives in Mexico. Desperate to help their daughter, the Santillans paid a smuggler to take them from Guadalajara to America three years ago. Ms. [Jesica Santillan] suffers from cardio restrictive cardiomyopathy, a condition of an enlarged and weakened heart and faulty lungs. The Santillans came to North Carolina because they heard it had good health care. The community here has been following Ms. Santillan's quest for a new heart since shortly after she arrived. Mack Mahoney, a 55-year-old Texas home builder, got things started. Mr. Mahoney was so moved when he read a newspaper article about the sick girl, who lived in a trailer with no windows, that he founded a charity to build houses for free to raise money for her surgery. He called it Jesica's Hope Chest and got Ms. Santillan on an organ donation list. Mack Mahoney, who led a fund-raising drive to pay for Jesica Santillan's medical care, yesterday with Ms. Santillan's cousin America Santillan. (Associated Press); Dr. [William Fulkerson], chief executive of Duke University Hospital, and Dr. [Karen Frush], director of children's services, said yesterday that Jesica Santillan had suffered ''severe and irreversible brain damage.'' (Reuters)

Unlike [Jesica Santillan], most patients who receive second heart transplants do so because their immune systems reject the donor organs. Because the heart and lungs Jesica received came from a person with a mismatched blood type, her body mounted a monster attack on the mismatched organs. Still, Jesica's parents, Melecio and Magdalena, who are from Mexico, celebrated that their daughter, 5 foot 2 and 80 pounds, had been given a second chance when new organs from a donor with matching Type O blood were found late Wednesday. As word of Jesica's plight spread, so did the hunt for organs. Duke Hospital officials pushed all the connections they had, not because of their mistake, they said, but because Jesica's condition was so dire. And worsening