Error occurred when confirming blood type
Sentinel events like the transplant error at Duke University Hospital in Durham, NC, often can be traced to a simple human failing by one individual, but risk managers look beyond that to ask how the system allowed the error to go undiscovered. At Duke, the problem was a lack of redundancy.
Duke’s root-cause analysis determined that Jesica Santillan, 17, died because the hospital’s organ-transplant process lacked redundant steps for confirming blood type and other compatibility factors.
Duke and the organ donor bank describe the series of events this way: When a heart became available for transplantation, Carolina Donor Services (CDS) found two potential recipients at Duke, both of whom had blood type A, the same as the organ. CDS contacted a Duke surgeon on call for adult heart transplantations. When the surgeon realized the first organ-matched Duke patient was a child, he referred the call to James Jaggers, MD, the surgeon in charge of pediatric heart transplants at Duke. CDS maintains that it gave Jaggers all the necessary information about the organ, including blood type. Jaggers then told Carolina Donor Services that the first potential recipient was not medically ready for the transplant, but that another pediatric patient — Jesica — was a candidate. Because the original offer was for only a heart but Jesica also needed lungs, the donor bank had to check on the lungs’ availability before giving Jaggers an answer about whether Jesica could have the heart.
Jesica, however, was not the second potential organ recipient with type A blood that CDS had identified at Duke. Jaggers did not discuss the second potential recipient with CDS because the second potential recipient was an adult, but Jaggers handles pediatric transplants. Jaggers says he inquired about the possibility of Jesica receiving the organs because she needed the transplant badly and he hoped the organs would be a match.
Jaggers gave Jesica’s name to CDS, thinking the company would look up pertinent information on the national list of patients awaiting transplants, according to a Duke statement that details how the mistake occurred. The donor bank proceeded on the assumption that Jaggers knew the heart was blood type A, because he had been given that information during the phone call. Jaggers thought the bank would confirm compatibility through its database before getting back to him with an answer.
The donor bank contacted the doctor of the second patient it had identified at Duke, but the organs were not a size match for that patient. CDS then called Jaggers back regarding Jesica, and at this point the crucial misunderstanding was about to occur. The donor bank confirmed that the lungs were also available, which Jaggers took as a confirmation that organs were a match in every way because he thought CDS had checked their database for a blood-type match for the organs. However, this didn’t happen, and as it turned out, the organs CDS procured did not match Jesica’s blood type. The transplant was set into motion despite the blood-type mismatch.
CDS says the organs arrived with paperwork and labels that clearly indicated their blood type. Duke says the blood-type match was not confirmed at that point because the team thought all compatibility had been checked.
A statement from Duke says, "Jaggers does not recall blood-type matching being discussed with CDS, but does recall the discussion including the donor’s height, weight, organ function, and cause of death. Dr. Jaggers assumed that they wouldn’t have called back and released the organs if they weren’t a match. This was a wrong assumption on his part."
Healthcare Risk Management has obtained a copy of a letter written by William J. Fulkerson, MD, vice president and chief executive officer at Duke University Hospital, to Deanna Sampson, director of policy compliance at the United Network for Organ Sharing in Richmond, VA, which oversees the organ transplant system. In the letter, Fulkerson writes, "We have concluded that human error occurred at several points in the organ placement process that had no structured redundancy. The critical failure was absence of positive confirmation of ABO compatibility of the donor organs and the identified recipient patient."
The letter continues: "Duke University Hospital has conducted a thorough root cause analysis of the event and the organ procurement process followed in the pediatric thoracic transplant program. During that review the lack of redundancy was recognized as a weakness. Validation of the ABO compatibility and other key data elements regarding the donor and recipient will now be performed by: the transplant surgeon, the transplant coordinator, and the procuring surgeon. The transplant surgeon will actively confirm the donor and recipient key data elements verbally. During the notification call to the transplant surgeon, the donor key data elements will be communicated. These data elements will be compared to the information in the transplant program’s database to confirm blood type compatibility, size compatibility, and if there are issues regarding anti-HLA antibodies. An additional verification will be accomplished via telephone contact with the organ procurement organization placement coordinator by the transplant coordinator."
Sentinel events like the transplant error at Duke University Hospital in Durham, NC, often can be traced to a simple human failing by one individual, but risk managers look beyond that to ask how the system allowed the error to go undiscovered.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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