Posted by: A.R. Cherian | September 24, 2009

Tragic surgery


Jesica Santillan was a 17 year-old girl from Mexico who received a heart-lung transplant in 2003 and died a few days later because of a medical error at the reputed Duke University Medical Center.

The main reason – wrong blood type. You would think that such a common and critical factor would have extensive checking and confirmation. The entire process failed to check Jesica’s blood type during numerous transactions.

Duke Medical Center took full responsibility and issued an apology (even publicly on 60 Minutes) but only after the news media got wind of the story.  The surgeon involved, Dr. Jaggers,  was extremely remorseful about the incident from day one. He accepted full responsibility, but the entire process had too many holes. To its credit Duke MC overhauled its transplant protocols almost immediately after Jesica’s first operation. JCAHO has also implemented more strict standards for all hospitals.

Tragedies like Jesica’s could be prevented. A 1999 study estimated that between 44,000 to 98,000 people die every year in the U.S. as a result of medical errors.

I’m divided about government health care, but one area I feel that the government should play a big part is the implementation of nationally-interoperable electronic health records (EHR) systems in hospitals and their suppliers.  Only the federal government has the clout needed to enforce this transition. So many lives can be saved by going digital and having computers cross-check thousands of critical factors better and faster than a human.

It’s going to be tough, but it’s where we have to go in order to cut costs and reduce unintended deaths. IT jobs to implement this need should grow.



  1. Les:
    Ten years ago, I started developing new ideas to improve patient care. After a lapse of several years, I have resumed work on the ideas. For several months now, I have been searching for someone to help me develop the ideas clinically. The “Silence is Deafening” as well as disheartening.
    I am hoping that perhaps you may be willing to help the project. The project Blog is ”
    If you read this Blog, you will find out about another tragic Duke University Medical Mistake.
    The “KID’S CLUB’ unit you will see in the photos is available for donation.
    Thanks, Duane Wyatt

  2. I wish you the best in your endeavors to bring these issues to light.

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