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, AMNews 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.

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.

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.