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The tragic mistake that cost Jesica Santillan her life should have been avoided as part of routine hospital safety procedures and a normal standard of care. Though Dr. James Jaggers has taken full responsibility, at least in his words, for Jesica’s death, it is time that he and Duke University Hospital take legal responsibility for their actions.

Had it not cost this young woman her life, the tragedy might be considered a comedy of errors: a doctor, several actually, failed to check the blood type of the organs they were implanting into the young woman; knowing that the organs could do irreparable harm they completed the operation once the mistake was known; and they took nearly two weeks to correct the error and find Jesica compatible organs. There is no disputing the fact that after the mistake was made, Duke and Dr. Jaggers gave Jesica the best medical care available in an attempt to save her life.

However, their due diligence after nearly killing her does not make up for the initial error. There should have been no way this could happen. In most transplant cases, the agency with the donor organs available sends a message to hospitals in need of those particular organs. In this case, the agency called Dr. Jaggers himself. The agency called offering the organs for another of Dr. Jaggers’ patients and he was aware enough of that case to determine that the organs were not suitable. It is not clear how he made this determination, but Dr.

Jaggers reports that he then asked if the organs might work for Jesica. He said they later called to tell him that he could have the organs for Jesica. But nowhere along the way did anyone actually check to make sure that the organs were in fact a match for Jesica. This should have been simple. The hospital would have had a record of her blood type; it was in her chart. The organ bank should also have had a record of her blood type as it would have been in the donor request. And, the organ bank most definitely had the blood type of the donor.

So whose fault it is? The truth is there is plenty of fault to go around. Perhaps it was the publicity surrounding the case or the desire to find a heart and double lung donor, not a commonly available transplant. But the basics of medical care were not followed. No one checked to see if the organ transplant was a match. Though ultimately Dr. Jaggers made the decision to go ahead with the transplant and final responsibility is his, any number of medical personnel along the way should have noticed the problem.

There is no doubt the hospital had to have blood in the operating room in case Jesica needed it during surgery. Simply the act of ordering that blood would have been a chance to match her blood type. Once the mistake was discovered, the hospital decided to continue with the operation. Arguably this may have been the right course of action because the transplant was nearly complete and Jesica could not be given back her old organs. And, the hospital told her parents of the mistake immediately.

However, the fact that the surgery had gotten so far without cross-typing is in itself an indictment against the hospital staff. If the wrong organs had been supplied to the hospital, it might have been different, but no one had bothered to look. Finally, the hospital took almost two weeks to publicly admit its error and find Jesica a new heart and lungs. Duke says the organ bank was informed immediately of the problem and began looking for new transplants, but they simply weren’t available.

They further argue that they did not make news of the mistake public because of a request from Jesica’s family. This argument fails to hold water because they had to know that a national appeal to donors and the families of potential donors might have resulted in organs for Jesica earlier. Leaving a decision of this magnitude to a grieving parent is irresponsible and reeks of an attempt to just let Jesica die and not expose the real problem. No parent wants to expose their dying child to the national media, but cooler heads should have prevailed and put out a public plea for new organs.

If the Santillan family did not want details of Jesica’s tragedy revealed, doctors could simply have said that she was rejecting the incompatible organs and deal with the whole truth of the matter later. Duke is going to try to argue that Jesica’s death, though a tragedy, was a simple human mistake. An overwrought doctor failed to check a major detail and none of his staff did either. They will argue that they did the best they could for Jesica and there are no guarantees that she could have survived for any length of time even with fully compatible organs.

But the truth of the matter is that Duke and its doctors violated the most basic of medical oaths, “do no harm”. Whether through neglect or procedural failure, they did not take the actions that would prevent harm from coming to Jesica while she was in their care. It’s more than just a failure to heal her. It’s that by the actions of the hospital and its surgical team, Jesica’s life was immeasurably shortened and her quality of life completely destroyed. The actions of this hospital and its surgical team were human error, but at some point, there must be enough redundancy built into the system to avoid human error.

The checks and balances for organ transplants were not in place and Jesica Santillan died because of it. Duke will argue that they learned from Jesica’s death and have put protocols in place so that this tragedy never occurs again. And, that is a fitting legacy to Jesica, that others will be saved because of her death. But that does not compensate her family and friends for the loss they suffered due to medical error. Perhaps others will escape their pain because of the hospital’s new protocols, but that does nothing to bring back Jesica and give her family back the life that was stolen from them.

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