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Practice Based Learning - Quality Improvement |
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A Death at Duke Edward W. Campion, M.D.
Last month, a 17-year-old girl died at Duke University Medical Center after receiving a heart–lung transplant from an incompatible donor. Her blood type was O, the donor's was A, and the mismatch was not recognized until after the transplant operation was over. In rare situations, ABO-incompatible transplantations have been performed intentionally. But in this case it was not intentional. A severe rejection reaction and multiple complications followed, and the patient died. The tragic event became a national news story. When a medical mistake receives this much attention, it affects the medical profession and even public policy. The patient's story was extraordinary, and this has only magnified the public's reaction to what happened. She had severe, congenital restrictive cardiomyopathy for which transplantation was the only hope. Her father was a truck driver near Guadalajara, Mexico, who was determined, with her mother, to find help for their sick daughter. Three years ago, they managed to enter the United States, bringing their daughter to Duke University Medical Center in North Carolina. She was put on the waiting list for heart–lung transplantation, which is a difficult, high-risk procedure performed fewer than 30 times a year in the United States. At first, her family turned to begging on the street to raise money for the operation. Then a forceful North Carolina businessman adopted her cause, and a grass-roots foundation began to raise money by building houses with donated materials and then selling them. The proceeds were to pay for a lifesaving transplant. It was the kind of story that hospitals use in upbeat brochures and public-relations efforts. But a simple, avoidable error turned it into a deadly nightmare. The family learned of the mismatch almost immediately, but about a week after the surgery, the story suddenly became public. For several days the national news coverage was intense. In the media's stories there was a sense of disbelief and outrage that echoed strangely with the recent reports about the Columbia shuttle disaster and the deadly fire in a crowded nightclub in Rhode Island. At Duke University Medical Center, the shaken chief executive officer went before the television cameras to admit that "an error was made." An event such as this weakens public trust and confidence and can affect everyone in the involved institution and beyond. Once the story became public, Duke seemed to respond by following a disaster plan designed to lessen the damage. There was full disclosure of the facts. Those in charge made public statements, and the hospital news office posted on its Web site the chronology of events and even videos of the public apologies. Perhaps because of all the publicity, an unusual second heart–lung transplantation was performed in a vain attempt to save the girl's life. In all, two hearts and four lungs were used to no benefit. Given the many patients waiting for organs, some uncomfortable ethical questions about the second transplantation remain. In the aftermath of such a disaster there must be an assignment of blame. The transplantation was a complex process involving the surgeons from Duke, the New England Organ Bank, which supplied the organs, and Carolina Donor Services, which handles transplants in North Carolina. All the institutions involved have initiated inquiries and are reviewing their procedures. The surgeon in charge stated publicly, "I am ultimately responsible for the team and for this error." But behind the scenes there will certainly be attempts to reapportion the blame, since a number of people could have caught the mismatch at a number of stages. Blame is inevitable, but it solves nothing. In the Institute of Medicine's 1999 report on medical errors and in research on safety, the key message is that patients are best protected by clearly established systems of care that are consistent and that cannot be circumvented. Systems do not become safer when those involved are told, "Be more careful" or "Try harder." At Duke, everyone had experience, expertise, and every intention of doing things right. Safety systems that are foolproof are essential in high-risk procedures such as transplantation, which involve complicated logistics, multiple organizations, and merciless pressure for speed. In the future we can expect more publicity after major errors in medical care, especially when communication breaks down and trust is lost. When patients and their supporters fear that something has gone very wrong, they may see the news spotlight as a rescue strategy or as a form of protection — almost as insurance. The spotlight can also offer an opportunity for revenge. Suddenly, an institution and its physicians are on trial before the public. And in this type of trial there are few rules. Physicians at Duke describe a disruptive, chaotic scene, with an invasion of excited lawyers, photographers, reporters, and family supporters around the pediatric intensive care unit. Dr. Duane Davis, surgical director of the transplantation program, said, "The worst aspect was that the patient became secondary to the conflict between caregivers and the patient's supporters." As the patient died, there were wild accusations charged with animosity. In our medical world, errors plus animosity usually result in lawsuits. At Duke the legal aftermath will almost certainly be long and expensive. The public will not forget what happened. Nationally, this tragedy has already weakened the prospects in Congress for malpractice-liability reform. The example set before the public will no longer be the large award to the woman at McDonald's who was burned by hot coffee, but instead, the girl who died at Duke after the major blood-type mismatch that no one noticed. Her story does not support the case for strict limits on the damages a jury can award. Instead, it increases the pressure for more regulation of complex systems such as transplantation. This tragedy joins the list of major errors that have created crises at other medical centers. Last year at Mount Sinai Hospital in New York, the death of a liver donor halted the transplantation program. At Johns Hopkins in Baltimore, clinical experimental research was stopped after the death of a volunteer in an asthma research protocol. And in Boston, many still remember the death in 1994 of a prominent woman after a massive overdose of chemotherapy for breast cancer. Americans are proud of our medical expertise, and all want the benefits that high-technology interventions can provide. But last month the country heard that things at Duke had gone terribly wrong for no good reason. This sad saga adds to the current unease about safety and about the control of our medical enterprise.
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