Editorial: A tragic error

In a tragedy of unspeakable sadness that has drawn the attention of the nation, Duke University Hospital officials admitted this week that on Feb. 7 a surgeon transplanted a heart and lungs of the wrong blood type into the body of 17-year-old Jésica Santillán. Now, as Santillán lies in her hospital bed awaiting a miracle, the Duke community and the medical profession should take time to reflect on the meaning of recent events and consider how such a mistake can be prevented from ever happening again.

Santillán's case has wrenched the hearts of everyone on campus and indeed of many Americans. She came to the United States from Mexico only a few, short years ago, brought by her parents in search of the expensive, complicated medical procedure that would spare her life. With the friendship of philanthropist Mack Mahoney, Santillán's hopes for basic survival improved greatly. Those hopes traveled the widest of emotional extremes two weeks ago, first with the news that doctors had found organs to transplant to Santillán, and soon after with the revelation that the organs were of the wrong blood type. Santillán's struggle to survive is an inspiration and a testament to the human spirit.

The events of recent weeks also require reflection and examination of the processes of Duke Hospital. That Santillán's flawed operation was so preventable, apparently due entirely to human negligence, makes it that much more tragic and that much more a call for action on the part of Hospital officials. The discrepancy in the organs' blood types led to the near-immediate rejection of the organs, and this should and could have been caught at several points during the frantic hours surrounding her operation. Tragically, the simple but extraordinarily essential task of matching blood types was not done.

Over the coming days, months and years, Duke Hospital will need to strengthen the safeguards that apparently failed so terribly. Where and when the doctors went wrong is still not entirely clear, but it is certain that those who sent the organs had no knowledge or had incorrect knowledge of Santillán's needs, either because they failed to ask or Duke Hospital officials did not tell them. More than the error of one person, this case demonstrates a systematic failure by Duke Hospital.

Aside from seeking a miracle transplant for Santillán, perhaps the best action Hospital doctors and administrators can take now is to be as forthright as possible regarding the mistakes of the case. The Hospital must hold itself up to the accountability of the public if it ever hopes to improve its procedures. A statement issued by Mahoney that administrators attempted to limit his ability to speak publicly, if true, would demonstrate an act of unconscionable insensitivity.

Duke Hospital remains one of the premiere research and clinical hospitals in the nation, and this case should not cause widespread fear about the Hospital's care. But it should serve as a cautionary reminder to all medical centers that no hospital is immune to such occurrences, and that if Duke hopes to stay a leader in health care, it cannot accept preventable tragedies such as these.