Medical Errors, Past and Present

A spokesperson from Milford Regional Medical Center said that in the time since the incident, the hospital has taken steps to ensure patient safety in the operating room to reduce the likelihood of such a mistake happening again. A lawsuit was never filed in connection with the incident.



Girl Dies After Receiving Wrong Heart, Lungs

On Feb. 23, 2003, 17-year-old Jésica Santillán died after receiving the wrong heart and lungs in a transplant operation Feb. 7. After a rare second transplant operation to attempt to rectify the error, she suffered brain damage and complications that subsequently hastened her death.

Santillán, a Mexican immigrant, had come to the United States three years before to seek medical treatment for a life-threatening heart condition. The heart-lung transplant that surgeons at Duke University Hospital in Durham, N.C., hoped would improve this condition instead put her in greater danger; Santillán, who had type-O blood, had received the organs from a type-A donor.

The error sent the patient into a comalike state, and she died shortly after an attempt to switch the organs back out for compatible ones failed. The hospital blamed human error for the death, along with a lack of safeguards to ensure a compatible transplant.

Dr. James Jaggers, the transplant surgeon who made the error, issued a statement the day following Santillán's death accepting responsibility for the mistake.

In the four years since the incident, Duke University Hospital has implemented a number of changes to ensure patient safety. Gail Shulby, the head of patient safety for the hospital, notes that Duke instituted a system of double-checking blood types and organ suitability before organ acceptance and before the organ was transplanted -- a change that also affected United Network for Organ Sharing policy on organ acceptance.

Additionally, Duke created a new chief patient safety officer position and established a patient council that provides the hospital with patients' perspectives regarding issues of safety and quality. The hospital also reorganized and strengthened its patient safety infrastructure, creating interdiscplinary teams that monitor patient safety and quality at services levels.

According to reports, Duke reached an agreement on an undisclosed settlement with the family. The terms of this settlement were sealed, but they included a stipulation that neither the hospital nor the family is allowed to comment on the case.



Family Claims Wide-Awake Surgery Led to Man's Suicide

Last April, a West Virginia man's family said inadequate anesthetic during surgery allowed him to feel every slice of the surgeon's scalpel -- a trauma they believe led him to take his own life two weeks later.

Sherman Sizemore, 73, was admitted to Raleigh General Hospital in Beckley, W.Va., Jan. 19, 2006 for exploratory surgery to determine the cause of his abdominal pain. But during the operation, he reportedly experienced a phenomenon known as anesthetic awareness -- a state in which a surgical patient is able to feel pain, pressure or discomfort during an operation, but is unable to move or communicate with doctors.

Some medical experts say between 20,000 and 40,000 patients every year may experience anesthetic awareness, which can be brought about by physician error or faulty equipment.

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