Transplant protocol has many checks

The Tampa Bay area's transplant hospital and organ provider guard against fatal errors with a ''multilayered'' procedure, a doctor says.

By SUSAN ASCHOFF, Times Staff Writer
© St. Petersburg Times
published March 25, 2003

The death of 17-year-old Jesica Santillan after a transplant with donor organs of the wrong blood type is a reminder that tragic medical mistakes can begin with something as mundane as failing to match letters on a chart.

Santillan died Feb. 22, two weeks after heart-lung transplant surgery at Duke University Medical Center. A rare, second transplant with correctly matched organs could not reverse her brain damage.

What went wrong?

And could it happen here?

Last year there were 42 heart transplants and eight lung transplants at Tampa General Hospital, the Tampa Bay area's transplant center. All Children's Hospital in St. Petersburg transplants kidneys and hearts into children.

"If this happens at a place like (well-respected) Duke, there's a sensitivity" by the public about the safety of all transplants, says Dr. Cristobal Alvarado, a cardiothoracic surgeon at LifeLink Transplant Institute. Alvarado performs surgeries at Tampa General Hospital. "We don't want people to be dissuaded about donating organs."

More than 3,000 people in Florida and more than 80,000 nationwide are awaiting transplants, according to organ provider LifeLink of Florida.

In Santillan's case, the mistake was not discovered until the first surgery was almost over. A checklist was not read, some match not verified; perhaps a blood type A mistaken for Santillan's O-positive.

The surgeon, Dr. James Jaggers, assumed compatibility had been confirmed when he was offered the organs and later failed to double-check that match, a violation of hospital procedures, Duke executive Dr. William Fulkerson said.

The organ provider, Carolina Donor Services, failed to ask Duke for Santillan's blood type before releasing the organ, its president, Lloyd Jordan, later told CBS's 60 Minutes.

United Network of Organ Sharing, the agency that oversees distribution of organs nationwide, requires that blood types of donors and recipients be matched before an organ is released for transplantation.

Duke has revised its procedures to prevent future mismatches, Fulkerson says.

In Tampa, Alvarado says, there is "a multitiered system of checks and balances" between Tampa General and LifeLink of Florida.

"There is a protocol that has to be followed every time."

Here is an outline of what happens at Tampa facilities:

-- Donor's blood is tested twice to confirm type.

-- Donor's blood type is checked against list of waiting recipients.

-- LifeLink identifies, confirms and reconfirms blood type of potential recipient.

-- Information, including blood type, is relayed to transplant hospital.

-- Two transplant teams, one to procure the organ and one to transplant the organ, begin their work.

-- The procurement team, including a LifeLink surgeon, travels to donor's location to remove organ, pack it for transport and obtain paperwork. A copy of donor's chart, which includes blood type, goes with the organ.

-- Container is also marked with donor's blood type.

-- Procurement surgeon accompanies organ -- usually hand carries it -- on the trip and walks it into the operating room at Tampa General.

-- Depending on travel time, surgery by the second team on the recipient may be under way. The time limit for viability of hearts and lungs, for example, is four to six hours outside the body. In most cases, surgery on the recipient does not start until organ has arrived.

-- Implanting surgeon checks blood type and patient's name on the organ. Team members recheck surgery patient's name and blood type.

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