Investigations by the CMS and the Joint Commission on Accreditation of Healthcare Organizations turned up multiple deficiencies in transplant procedures at Duke University Medical Center. A 54-page report from the CMS said Duke failed to provide leadership to ensure a safe program for patients such as Jesica Santillan, the 17-year-old whose heart-lung transplant was fatally botched in February because of a blood-type oversight. Meanwhile, the JCAHO downgraded the medical center's full accreditation to a lesser standing, accreditation with requirements for improvement in six areas, including governance, information management planning and assessing staff competence. Both reviews cited a lack of redundancies to ensure the compatibility of organs and the need to improve coordination between Duke and organ-procurement authorities. In a statement to hospital staff, Duke said many of the problems cited were addressed soon after the first transplant, including a process for verifying blood type four times prior to surgery. The medical center also merged the pediatric transplant program with the adult program, which has more experience. -- by John Morrissey
CMS, JCAHO find flaws in Duke transplant program
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