Jessica Santillan, a young lady barely eighteen years of age
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Topic: NSG 430: Critical Care Nursing
Details: Please respond to my peer discussion post.
Jessica Santillan, a young lady barely eighteen years of age, was originally from Mexico. She had earlier been diagnosed with obstructive cardiomyopathy, and the condition informed her family’s decision to cross the Mexican-US border. They managed to find settlement in a caravan in North Carolina where Jessica was lucky to access a renowned philanthropic surgeon at Duke University Hospital, Dr. James Jaggers. In May 2002, the girl made it to the transplant list awaiting a heart and lung donation. About nine months later, the organs became available, but Dr. Jaggers considered them unsuitable. Upon consulting with the donor coordinator, Dr. Jaggers was informed that the organs would be analyzed and he would be given the report (Kopp, 2003).
The report came in an hour later, giving the organs a clean bill of health. Nevertheless, the issue of blood groups was never raised, and given that the doctor did not have the blood details at home, he assumed that the coordinators had verified the suitability. This was, however not the case as the organs were from a type A donor while Jessica was of type O. Unfortunately, the blood groups went unchecked until the discovery was made by a lab technician an hour and a half into the surgery. All efforts to support the girl’s life backfired, and even though the correct heart-lung donation became available after some time, Jessica suffered brain death three days after the surgery (Kopp, 2003).
The error happened because of negligence. All the people involved in the process assumed that the blood group’s details had been confirmed, and thus none of them bothered to give it a thought. This was in contrast to the Hippocratic oath, which states the proper conduct and obligations of physicians. Part of the oath expresses the willingness of doctors to apply all the required measures for the benefit of the sick, and this was not done (The Hippocratic oath, 2010). It was thus an act of negligence and not maleficence because whereas the former involves acts of omission, the latter entails the commission of harmful acts (Omonzejele, 2009). The responsibility and liability in a medical error like this should be taken by all the people involved in the process, including the doctors, nurses, and pharmacists. To help in preventing and reporting such errors, several state-mandated systems have been created. Examples include the New York Patient Occurrence Reporting and Tracking System (NYPORTS) and Pennsylvania’s Medical Care Availability and Reduction of Error (MCARE) Act of 2002 (Wolf & Hughes, 2008).
References:
Kopp, C. (2003, March 16). Anatomy of a mistake. CBS News – Breaking news, 24/7 live streaming news & top stories. https://www.cbsnews.com/news/anatomy-of-a-mistake-16-03-2003/
Omonzejele, P. (2009). The obligation of non-maleficence: Moral dilemma in the physician-patient relationship. Journal of Medicine and Biomedical Research, 4(1). https://doi.org/10.4314/jmbr.v4i1.10664
The Hippocratic oath. (2010). Clinical Examination, xvi. https://doi.org/10.1016/b978-0-7295-3905-0.50022-3
Wolf, Z. R., & Hughes, R. G. (2008, April). Error reporting and disclosure – Patient safety and quality – NCBI bookshelf. National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov/books/NBK2652/
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