In the article Jesica’s Story: One Mistake Didn’t Kill Her – The Organ Donor System Was Fatally Flawed explained the story of Jesica Santillan. Jesica was born in Guadalajara, Mexico. As a child she didn’t have stamina and as she grew older, she would get tired more easily. Her parents noticed this change and sought medical attention. After tests and other medical investigation, the doctors determined she had a weak heart. They felt her best chance of survival was further medical treatment in the United States.
Her parents took her to North Carolina because of family, the Mexican population, and nearby medical facilities. While Jesica Santillan was in school, the school officials found she was having health problems and sent her to Duke. Duke eventually decided to give her a heart and lungs transplant. Tragically, her heart-lung transplant went horribly wrong and Jesica died. Her blood type and the donor’s did not match. That small error cost Jesica Santillan her life.
The Aftermath
Immediately following the tragedy, the surgeon, Dr. James Jaggers, took responsibility for her death. He said that since he failed to notice the difference in blood type, it was his fault. This tragedy, however, led to investigations which found several checkpoints when people should’ve checked the blood type but didn’t. They determined that Dr. James Jaggers was just one person in a series of mishaps that led to Jesica’s death. Jesica died because of a systemic problem, not because of one person’s failure.
I agree with the tone of the article that the transplant system, as a whole, was where the mistake was made. Although the surgeon, Dr. James Jaggers, should have checked the blood type before starting the surgery, he should not be the only one held responsible for the mishap.
Systemic Problems
In the existing system, everyone involved in the transplant process took everyone else’s word on the blood type, but did not check it.
The system should be set up so people involved cannot fail unless they go against the system. Dr. James Jaggers failure was publicized and received a lot of attention. There were other also other cases where blood types were not matched for the transplants. In many cases, those other doctors were lucky because their patients didn’t die after the operation.
How Can System’s Be Successful?
For a system to be successful, most, if not all, chances for failure or mishap must be eliminated. A proper system is setup so the chance of human error is minimal. Usually, the perfect system can’t be created all at once. Rather, the initial system is created, modified, and improved on a regular basis. Little by little the system becomes much stronger as all the little challenges are worked out.
The ideal transplant system would have several checks. Each person would review the previous work and sign their name. That would increase the number of checks and catch errors along the way before an error became life threatening. In the case of the Duke medical system/organ procurement organization, there weren’t enough checks to catch the error of the blood type.
Leadership Implications
When you are in organizational leadership, regularly check out policies and procedures to ensure there is clear guidance for those implementing it. Also, every time there are inconsistencies, errors, or other problems, take a deep look at the cause. Why did it happen? Was it due to human error? Why did the human error occur? What decision did the individual have to make without clear guidance?
When you ask these questions, identify and provide more guidance to eliminate the problems or future possible errors. Taking a deep look will improve the process and increase the chances of repeatable success.
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