Jesica’s Story – One mistake didn’t kill her–the organ donor system was fatally flawed

http://business.unr.edu/faculty/simmonsb/badm720/dukemedical.doc

This report talks about how a young woman, Jesica Santillan, died during a heart-lung transplant.  The cause of her death was that her blood type did not match the donor’s blood type.  Jesica’s death could have easily been avoided had there been better procedures in place in the system.  Perhaps, even though her surgeon, James Jagger, ultimately took responsibility for Jesica’s death, her death was result of the medical system failing her as a whole.

I think even though the medical system puts all accountability on the surgeon, there should be better procedures to avoid elementary mistakes like this by putting multiple checkpoints in place.  What I also noticed in this report was that there was a huge lack of communication between organizations that handled the process.   Although none of these processes are officially called “check points,” I can’t help but to think that someone would have caught the blood-type mismatch had there been better information sharing in the organization.   For example, I believe this could have been easily caught by the senior attending physician had he been provided with more information than the patients name and size!

It’s all about teamwork, assuming responsibility and taking pride for what you do.  Lack of resources and information played a huge role in this tragedy.  There have been many times that I have been so tied up in many tasks that I forgot to even consider the most trivial things that affected what I was trying to accomplish.  Those times always made me wish I was getting more help from my co-workers and I had someone to check my work to prevent me from embarrassing myself and my company in front of a customer.

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~ by aliahmadian on February 22, 2010.

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