Passing the Buck:Organ procurement director,no requirement to double check bloodtype

[NRSKarenRN, BSN, RN]

March 17, 2003

Group Denies Breach in Transplant Error

By THE ASSOCIATED PRESS

Filed at 1:01 p.m. ET

RALEIGH, N.C. (AP) -- The head of a donor services group that helped locate organs for the teenager who died after a bungled heart-lung transplant says his organization's failure to double-check the patient's blood type was not a breach of policy.

Jesica Santillan, 17, died Feb. 22, more than two weeks after a transplant operation at Duke University Medical Center in which she was given organs that did not match her blood type. Correctly matched organs were implanted Feb. 20, but she died two days later.

``Do I wish we had gone back and checked Jesica's blood type? Yes,'' Lloyd H. Jordan Jr., executive director of Carolina Donor Services, told The News & Observer of Raleigh. ``I'm not backing away from that at all. Everybody involved wishes things had been done differently.''

Duke admitted its own errors and has implemented new rules for handling organ transplants to prevent another mismatch.

Jordan said in a CBS' ``60 Minutes'' interview broadcast Sunday that his organization didn't know Jesica's blood type before it released the heart and lungs.

``We could have requested her blood type, and I wish we had,'' Jordan told the CBS program.

But he told the newspaper that, until Jesica's case, organ procurement agencies never considered it necessary to double-check to make sure that doctors were requesting the right organs for their patients.

``They've done this hundreds and hundreds of times, and never once before this have they brought up a patient who was not blood-list compatible,'' Jordan said.

Jordan said Carolina Donor Services served as a liaison between Duke and the New England Organ Bank when the organs became available in Boston on Feb. 7. The New England Organ Bank checked a match list that contained a different patient of the surgeon, Dr. James Jaggers, and that patient's blood type was a match, he said.

New England called Carolina Donor Services, which in turn called Duke.

However, Jaggers declined the organs for that patient and instead requested the organs for Jesica even though she was not on the match list. That is a common practice among transplant surgeons, so it did not raise any red flags at the organ bank, officials said.

Since Jesica's death, Duke has said it has already established a new system to triple-check blood type compatibility.

http://www.nytimes.com/aponline/national/AP-Transplant-Error.html?pagewanted=print&position=top

[renerian, BSN, RN]

Glad to see something changed over this snaffoo.......high cost.

renerian