24 June 2011
As I prepare to spend a week on the lung transplant service at Duke, I am hesitant to rehash the old scandals and painful wounds of Duke’s past. But as a medical writer, and former Duke employee, it would be dishonest to ignore this history.
As many people know, almost 10 years ago there was a terrible medical mistake that resulted in tragedy after a mismatched heart-lung transplant in a teenaged girl, which led to her death. To their credit, in an age of increased medical litigation, and under intense scrutiny, Duke has been honest and open; they admitted their mistake, and have used this tragedy to set procedures in place, which now make Duke University a forerunner in patient safety. There is an excellent article on Medscape.com about this event and the immediate aftermath (but requires subscription). If I get any requests – I will re-post the article here.
In fact, Duke is not the only transplant center to have experienced this sort of medical mistake. Vanderbilt (my alma mater) even published a study based on their experiences.
As someone who knows many of the surgeons involved, I know that as tragic as this episode was, it is only part of the story of these surgeons who perform life-saving operations every single day.
Root cause analysis of a mismatch
Update: 2 July 2011
During my visit down at Duke, this case kept coming back to me. As a former Duke employee, I can imagine how devastating this must have been to Duke employees throughout the facility. One of the things that I always liked about Duke was the culture of patient service and caring. People are proud to work at Duke; janitors, receptionists, cooks, nursing assistants, surgeons, nurses all demonstrate this pride visibly by the wearing of Duke paraphernalia, and personally, through small but important gestures. It’s something that every visitor who ever came to our office in Virginia always remarked on. “When I was down at Duke” they would all say – and then similar stories would emerge “I was lost, and didn’t know what to do, but then a person from radiology was walking by. I asked them for directions and they took me right where I needed to be.”
But it was still hard for me to imagine the immediate aftermath [I started working for Duke in 2007, well after this incident]. But I don’t know how the surgeons felt – and in some ways I was too chicken to ask them. But I also didn’t ask the transplant service about Jesica Santillan because I wasn’t sure what kind of answer they could really give. Of course it was a tragedy, of course, they are sorry. But are there really words for people to express true regret?
Instead, I just looked around, and observed the transplant procedures and looked at the actions Duke has taken in the years since then. In doing so, I can honestly say that Duke has learned from this. Despite HIPAA related anxieties in the medical field* and an era of zealous information hoarding, Duke has enacted steps to ensure this sort of catastrophe never occurs again – by acknowledging that “the need to know” extends beyond the surgeons to include other members of the surgical team. Anyone who has ever been inside an operating room knows that some information is widely shared with operating room personnel, and some isn’t. That is no longer the case at Duke – every member of the team is informed and involved in fact checking, and double checking patient information; from the moment an organ is offered, during organ retrieval / delivery and implantation. All of the surgical nurses know, and the information is double checked when the patient arrives in the operating room. Important patient information is posted in large letters on a whiteboard in the OR. Then anesthesia and the perfusionists confirm this information with the surgeon present during the time out procedures.
This information is relayed several times during phone calls to the procuring surgeon, before leaving Durham, after the flight – arriving at the donor hospital and before leaving to return to Durham. When the procuring surgeon arrives to the Duke, organs in tow – this information is again verified, by a different individual at the operating room front desk before the organs are taken back to the operating room. Then with the organ in the room – the verification process (both the recipient and donor information) is repeated again; circulating and scrub nurses participate – lab personnel participate. Everyone participates.
There’s some redundancy – in fact, it feels a little like cramming for a final exam. (If Joint Commission suddenly appeared at 3am to quiz any of these people – everyone would pass with flying colors.) But it’s also been incorporated into Duke corporate culture and no one seems to give it a second thought. No one complains, no one sighed or shrugged, everyone knows the price they paid in the past – and no one is willing to repeat it.
* Note: None of the new procedures at Duke violate HIPAA or the principles of HIPAA (patient privacy act).
Thoracic Surgery 