Despite the high-profile medical error that claimed the life of Jesica Santillan, 17, on Feb. 22 at Duke University Medical Center, Durham, N.C., by press time few healthcare organizations had offered suggestions or policies that might prevent future transplantation mistakes, a leading transplant surgeon says.
Robert Wood Johnson University Hospital in New Brunswick, N.J., said the night before Santillan died 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. "I would think this would be a prime opportunity to review policies to ensure that a tragedy like this does not happen again."
The hospital now will require two nurses to verify compatibility with the transplant patient when the organ arrives in the operating room. 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," he says.
However, no major hospital or health system other than Duke and Robert Wood Johnson had come forward with policy reviews in the immediate wake of the Santillan case, according to Freudenberger.
Neither the American Hospital Association nor the American College of Surgeons would comment on the matter.
"We're not a regulatory agency," ACS spokesperson Sally Garneski explains.
Duke surgeon James Jaggers, M.D., took responsibility for the mismatching of donated organs to Santillan's blood type shortly after completing a surgery on Feb. 7, though chronologies reported from both Duke and Carolina Donor Services in the Washington Post indicate each organization assumed the other was checking blood types of the donor and recipient.
A second transplant on Feb. 20 was unable to save her life.