Despite the high-profile medical error that claimed the life of 17-year-old Jesica Santillan over the weekend, few in the medical community have stepped forward to offer suggestions or policies that might prevent future transplantation mistakes, says a leading heart transplant surgeon.
Robert Wood Johnson University Hospital in New Brunswick, N.J., said Friday evening--even before Santillan was declared dead on Saturday--that it would add a fifth protocol to its safety checking process before proceeding with organ transplant surgeries.
"There is no time too early to add patient safety checks," says Ronald Freudenberger, M.D., director of heart failure and transplant cardiology at the hospital.
"We met on Thursday of last week to review our policy," Freudenberger says. "I would think this would be a prime opportunity to review policies to ensure that a tragedy like this does not happen again."
The New Jersey academic hospital now will require two nurses to check an organ's compatibility with the transplant patient when the organ arrives in the operating room. This step is the second nurse's check in the process; an on-call nurse coordinator already checks transplant organs when they arrive at the hospital, Freudenberger says.
"This is very similar to protocol for blood transfusions," Freudenberger says.
However, by Monday, aside from Duke and Robert Wood Johnson, no other major hospital or health system had come forward with policy reviews or changes in the wake of the Santillan case, according to Freudenberger.
Neither the American Hospital Association nor the American College of Surgeons had anything to say on the matter.
"We're not a regulatory agency," ACS spokesperson Sally Garneski explains.
Duke University heart-lung transplant surgeon James Jaggers, M.D., took responsibility for the transplant team and the error of mismatching donated organs to Santillan's blood type shortly after completing a surgery on Feb. 7. Her body rejected the heart and lungs.
A second transplant on Feb. 20 was unable to save her life, and Santillan, a Mexican national, died on Saturday.
Newsweek magazine reported Sunday that Jaggers "does not recall" blood type being discussed when he secured a heart and lungs for the first operation.