Reviews

When Jesica died

A teenager's death has highlighted medical errors and transplant problems in the United States

   Sunday 16 March was a bad media day for American medicinea really bad day, considering it came during annual Patient Safety Week.

The popular CBS investigative programme 60 Minutes broadcast "Anatomy of a Mistake," detailing the simple error that killed transplant patient Jesica Santillan. The New York Times headlined its Sunday magazine "Half of what doctors know is wrong" and devoted the issue to "exploring medicine and its myths."

Coming on the same day and reaching millions, these two events may be a watershed in focusing public attention on the related problems of medical errors, transplant mistakes, and the malpractice mess.

Just four days later, on 20 March, the New England Journal of Medicine published a damning Perspective article about the Jesica Santillan case entitled "A Death at Duke" (NEJM 2003;348:1083-4)[Free Full Text]. It said, "When a medical mistake receives this much attention, it affects the medical profession and even public policy."

Jesica was a 17-year-old Mexican girl with congenital restrictive cardiomyopathy. Her parents had the family smuggled into the United States to find her a heart-lung transplant. They moved to Durham, North Carolina, home of Duke University Medical Center, one of America's best. They lived in a trailer and begged on the streets to raise money for her transplant. A local businessman started a foundation to help. Jesica was put on the transplant list at Duke. She waited three years until a donor was found.

On 7 February surgeon James Jaggers had almost completed the operation when he learnt that the organs came from a donor with type A blood, incompatible with Jesica's type O. The story became front page news. Jesica was kept on life support systems while a second transplant was soughtand, astonishingly, found. Despite the second transplant, Jesica died from irreversible brain damage on 22 February.

The 60 Minutes presenter Ed Bradley asked, "How did an operation performed by a team of expert surgeons go so wrong? What it came down to was a failure to communicate basic information. Not one of the more than a dozen people working at Duke Hospital and the two organisations responsible for getting the new heart and lungs to Jesica Santillan ever cross-checked her blood type before the surgery to see if it was a match with the blood type of the donor."

Jesica's story was followed in the national news by a Texas lawsuit. A 17 month old girl died after receiving a partial liver transplant from her father, who was incompatible, instead of from her mother, who was compatible. Apparently a laboratory mixed up the results of blood typing on the girl's parents.

The day of the 60 Minutes report, the New York Times Sunday magazine included an article: "The Biggest Mistake of Their Lives. What is it like to be the survivor of a medical error? Four patients speak about the operations that divided their lives into before and after." Two patients had gauze or an instrument left behind. Both required further surgery, losing time from work, and one was permanently disabled. Another patient underwent radical, disfiguring jaw surgery after a misdiagnosis of cancer. In the fourth case, a man's kidney transplant from his sister failed because it was put in on the wrong side. He was forced on to dialysis and could not continue in his job, which required travel.

Three years ago the Institute of Medicine report To Err is Human: Building a Safer Health System (Washington, DC: National Academy Press, 2000) called for no-fault reporting of medical errors and "near misses," so that problems could be corrected instead of trying to find someone to blame. Such systems are used in the airline industry.

Doctors have complained about skyrocketing insurance premiums, which they say are caused by huge jury awards in malpractice cases. President George W Bush strongly supports limits on jury awards. On 13 March the Republican-controlled House of Representatives passed legislation limiting non-economic damages, such as those for pain and suffering, to $250 000, despite testimony by victims such as a woman who had a double mastectomy because of a mix-up in pathology reports. The limits would apply to doctors, hospitals, nursing homes, and other providers of health care. Patients who are harmed could still sue for lost wages or the cost of medical care to treat the injury. The House also passed a bill creating a voluntary system to report medical errors, but opposition Democrats said it lacked teeth for enforcement.

A bill limiting malpractice awards is being considered in the Senate, its chances weakened by stories like Jesica's. If the bill is passed, few lawyers would take Jesica's case, since there were no economic damagesshe did not hold a job. Litigation would be costly, even though the Senate may raise the maximum award to $500 000.

Janice Hopkins Tanne, medical journalist. 

New York