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Case of jesica santillan and duke medical center

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    Assignment ID: FG133135956

    The first report of the Institute of Medicine (IOM) titled “To Err Is Human” has caused medical errors to be considered as a major priority worldwide. The findings from studies on medical errors occurring in blood transfusion practices disclose that 3.7% of patients in the U.S. are vulnerable to adverse events during a hospital stay. An adverse event is defined as an unintended injury or complication with the severity ranging from very little to fatal consequences (Institute of Medicine, 2000).

    Leader in the field of medical ethics, Sazama’s (1990) report found the following:

    Error may occur during all therapeutic procedures among which blood transfusion is one of the most common high risk procedures. Since transfusion errors may result in serious morbidity or mortality, they are categorized as critical medical errors. Ordinarily much attention is paid to the safety of the blood products prior to transfusion, and not necessarily to the processes involved in the actual blood transfusion at bedside where approximately 70% of the errors have been reported to occur. Mistransfusion of ABO-incompatible blood poses a greater risk for transfusion recipients than the risk of transmission of infectious disease, accounting for 37% of all reported transfusion-associated fatalities in the United States. Published reports cite an incidence of ABO discrepancy due to inappropriately identified specimens ranging from 1 in 517 to 1 in 3,400 samples. Considering that approximately two-thirds of transfused units will be ABO compatible by chance alone, and that the true incidence of transfusion errors has been estimated to be as high as 5 times the number of detected errors, the risk of mistransfusion may be severely underestimated. (p. 583-590)

    For this discussion, read about the case of Jesica Santillan and Duke Medical Center in The Jesica Santillan Tragedy: Lessons Learned Download The Jesica Santillan Tragedy: Lessons Learned. Then, discuss and answer the following:

    1.In your own words, discuss the events surrounding this case. What happened?

    2.What are your thoughts and feelings about this case?

    3.What are the lessons to be learned by this case and how could this have been prevented?

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