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Duke continues quest for culture of safety

Patient Safety Monitor Alert, February 24, 2005

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Two years ago yesterday, Duke University Health System (DUHS) experienced a medical error that sparked a major grassroots patient safety campaign.

Jesica Santillan underwent an organ transplant at Duke University Hospital in 2003, but the organs were incompatible with her blood type. Her body rejected the transplant, and 15 days later, she passed away, according to The Chronicle, the independent newspaper at Duke University.

Within a month of her death, administrators put in place redundant blood-matching checks, hung posters reminding doctors of blood compatibility, and merged the pediatric heart transplant program with the adult heart transplant program to ensure consistent treatment. Administrators wanted to be sure that a similar accident would not occur.

Officials at the hospital system say that patient safety measures were in place before the incident, but their effect hadn't been fully realized. Recently, the Duke University Human Simulation and Patient Safety Center-which was created a few years before Santilan's death-has become a leader in patient safety research. The center allows physicians and medical students to simulate emergency situations with a computer-controlled mannequin and allows researchers to evaluate team dynamics and recognize communication problems.

In its quest for a culture of safety, DUHS has experienced other incidents since Santilan's death, including:

• the discovery of surgical tools cleaned in elevator hydraulic fluid at Duke Health Raleigh and Durham Regional Hospital in November and December of 2004
• the death of a Durham Regional Hospital patient who jumped out of a fifth floor window in August 2004

Administrators hold that DUHS maintains safe facilities but that the system needs to move the culture away from one of individual blame to one of system-level culpability. Placing the blame on the system allows the failure to be addressed with open sharing of ideas about prevention.

"The problems that we have are system problems," said Michael Alton, MD, clinical operations director for the Pediatric Patient Safety Initiative. "The challenge is to put safeguards in place so we can prevent a mistake from getting through the system."

To read the complete Chronicle article, click here.

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