Transplant tragedy spurs system checks

Safeguards are being instituted at organ transplant centers to try to better protect against matching errors.

By Susan J. Landers, amednews staff. April 28, 2003.

Washington -- News that a tragic mismatch between patient blood type and donated organs occurred at Duke University Health System sent shock waves across the country.

"How in the world could that happen?" thought Robert Robbins, MD, director of the Heart and Lung Transplant Programs at Stanford University, when he heard about the incompatible organs that were provided to 17-year-old Jesica Santillan in February.

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Even though another set of organs was soon found, the teenager died on Feb. 22, leaving her family, as well as the transplant surgeon at the Durham, N.C., facility, devastated.

Dr. Robbins wasn't the only one at California's Stanford who was shaken by the mismatch. "Within hours as I was walking down the hall every administrator in the hospital asked, 'How can you make sure it isn't going to happen here?' " he said.

Stanford, the University of Pittsburgh, and Vanderbilt University in Nashville, Tenn., as well as many other transplant centers, certainly did some introspection. No one at those institutions ever had a similar incident but the thought was, if it happened at Duke, it could happen anywhere.

Stanford went through every step of its process and double-checked that the correct blood type was recorded for each patient.

81,000 people are waiting for organ transplants.

Vanderbilt did the same. "We forced the system to be duplicative," said Wright Pinson, MD, director of Vanderbilt's transplant center. The center now requires two different sources for a blood type, one from the donor hospital and the other from a laboratory selected by the center's organ procurement organization. The same is true on the recipient end, said Dr. Pinson.

Vanderbilt also has a new form that is signed in the operating room to document that all the written verifications of compatible blood type are present and accounted for.

In addition, Vanderbilt is now requiring two people to check that the correct blood type for a waiting recipient is entered in the computerized registry maintained by the United Network for Organ Sharing, which manages the nation's organ transplants.

"There's a form that sits under the computer, and every time we enter a new patient, two people have to sign that form," said Dr. Pinson.

The need for duplication was evident, said Dr. Pinson, when a review turned up written mistakes in blood types already entered into the computer.

An analysis of the University of Pittsburgh's transplant processes found that all the redundancies built into the program made it about as safe as possible, reported Kenneth McCurry, MD, director of Pittsburgh's Lung and Heart-Lung Transplant Program. Even so, a decision was made to retain the written documentation on blood type.

Duke University immediately launched its own investigation of the tragedy and has already put in place measures to help ensure that all parties have accurate information about the blood type of the recipient and the donated organs.

UNOS is also investigating and expects to have a report completed in June.

What went wrong?

Most agree that human error compounded by the desperate need for a heart and lungs for a very sick patient caused the mismatch.

"There was an assumption on the part of the surgeon that the organs would not have been released to him unless the donor service had validated the match," said Ralph Snyderman, MD, president and CEO of Duke University Health System.

Transplant centers are creating duplicative checks and building in redundancies.

The donor service, the New England Organ Bank in Massachusetts, had generated a computer list of potential recipients who were medically compatible with the donor and offered the available heart and lungs to Duke surgeons for two other patients. The organs were turned down for the matching patients but the word was passed that Santillan was in need.

How the organs came to be released to Duke for Santillan and how the Duke surgeons proceeded to use them without checking the blood type is still under investigation.

Dr. Snyderman attributed the mismatch to "human errors and an insufficient backup system."

Duke now has a backup system that Dr. Snyderman describes as being similar to a checklist that is reviewed by an airplane pilot and co-pilot before takeoffs.

Duke has also used this occurrence to look at the broader issue of patient safety at its facilities, said Dr. Snyderman. Even though nothing of similar magnitude had ever occurred at Duke before, an examination is under way in all areas of patient care to determine what might pose a high risk to patients, he said.

Although Duke transplant surgeon James Jaggers, MD, said he was ultimately responsible because he had accepted the mismatched organs, there are other players in the complex procedure. In addition to the Massachusetts procurement center, Carolina Donor Services in North Carolina served as the conduit of information between Duke and the New England Organ Bank.

Carolina Donor Services has said it accurately communicated blood types to Duke and the New England Donor Bank. The New England Donor Bank referred calls on the mismatch to UNOS, which also operates the national Organ Procurement and Transplant Network. UNOS is deferring comment until its investigation concludes.

In the meantime, UNOS is asking that all organ procurement organizations make sure their staffs are thoroughly familiar with the most current policies.

The Southwest Transplant center in Dallas is one such organization that took a hard look at its policies to make sure no holes existed, said spokeswoman Pam Silvestri.

"That might have been the one positive here," she said. "No matter how good you think things are, it gave us an opportunity to look at it again. I think that's good advice in any field."

Another hope that arose from the highly publicized case is that the attention drawn to the need for organ donors might boost donations. There are nearly 81,000 people now waiting.

"My bottom line is that [the organ transplantation system] is by and large a safe system and the reason something like this happens is that organs are difficult to come by, especially heart and lung blocks," said Stuart Sweet, MD, PhD, medical director of the Pediatric Lung Transplant program at St. Louis Children's Hospital.

"People are trying their best to get organs for sick patients, and for whatever reason there was a communication breakdown in this particular instance that caused a tragedy."