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A Death RetoldJesica Santillan, the Bungled Transplant, and Paradoxes of Medical Citizenship$
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Keith Wailoo, Julie Livingston, and Peter Guarnaccia

Print publication date: 2006

Print ISBN-13: 9780807830598

Published to North Carolina Scholarship Online: September 2014

DOI: 10.5149/9780807877524_wailoo

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All Things Twice, First Tragedy Then Farce

All Things Twice, First Tragedy Then Farce

Lessons from a Transplant Error

(p.97) All Things Twice, First Tragedy Then Farce
A Death Retold

Charles L. Bosk

University of North Carolina Press

This chapter examines the transplant error in the Jesica Santillan's case and the main actors in the story (from Duke University Medical Center to Carolina Donor Services, from the United Network for Organ Sharing (UNOS) to the surgeon Jim Jaggers) in order to frame our understanding of medical mistakes as individual, institutional, and system-wide phenomena. Jesica's story illustrates how stakeholders transform celebrated cases to provoke discussions in public arenas and use as dramatic examples of formulating policies to prevent and/or reduce medical errors and achieve patient safety. Focusing on the theoretical understandings of systems error, the chapter analyzes how this mistake was understood at the time and examines the steps taken by the Organ Procurement Organizations (OPOs) and Duke to reassure the public that the causes of this error had been discovered and fixed.

Keywords:   transplant error, Jesica Santillan, Duke University Medical Center, Carolina Donor Services, United Network for Organ Sharing, Jim Jaggers, medical errors, patient safety, Organ Procurement Organizations

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