This paper analyzes the Jessica Santillan organ transplant case at Duke Hospital, exploring how cultural barriers, language differences, and health literacy gaps between a Mexican immigrant family and medical staff contributed to a fatal medical error. The paper defines key communication barriers—cultural, social, language, and health literacy barriers—and examines the breakdown in communication between UNOS and surgical staff that resulted in a blood type mismatch. It reviews the institutional changes Duke Hospital implemented following the tragedy, including electronic health records and double-check protocols, and discusses stakeholder communication strategies for addressing medical errors and rebuilding trust.
In the multicultural world we live in, cultural and social barriers to communication are plentiful. A cultural barrier is a wall between people due to identity differences. Social barriers are those created by a group of people toward strangers or others who are not part of their group. Health literacy is another critical barrier in healthcare settings, defined in the Institute of Medicine report as "the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions" (Glassman, 2013). For people from different cultural backgrounds, health literacy is affected by belief systems, communication styles, and understanding and response to health information. Health literacy affects a person's capacity to fill out healthcare forms and share important health history with providers.
Language barriers compound these challenges significantly. When patients and their families cannot communicate in the language spoken by healthcare providers, the risk of misunderstandings and errors increases substantially. These barriers often interact with cultural differences, creating multiple layers of miscommunication. Understanding and addressing these barriers is essential to providing equitable healthcare and preventing medical errors.
The tragic case of Jessica Santillan illustrates how communication barriers can have fatal consequences. Jessica's family entered the country illegally and was unable to speak English, which made it difficult for the family and physicians to communicate about her health. There was both a language barrier and a health literacy barrier between the physicians and Jessica's family. These barriers may have contributed to the untimely circumstances that followed.
However, the most critical failure was organizational rather than cultural. A communication breakdown occurred between the United Network for Organ Sharing (UNOS) and the physicians performing the transplant. While UNOS informed the transport doctor about the blood type, the transport doctor was unaware that Jessica's blood type was O. Dr. Jaggers, the surgeon, was not aware of the mismatch until the surgery was almost finished. When UNOS used word-of-mouth communication instead of paperwork to inform the transport doctor, this caused the wrong organs to be transplanted. Jessica's body rejected the organs, which ultimately caused her death. Had Dr. Jaggers double-checked the blood type before surgery, this preventable tragedy might have been avoided.
As soon as Dr. Jaggers was informed of the mismatch, the administration should have immediately contacted a translator and explained to the parents what took place and what the next steps would be. The failure to bridge the language barrier at this critical moment further compounded the family's trauma and the hospital's responsibility.
Following Jessica's death, the medical world has implemented significant improvements in how patient medical history is transferred and verified. Duke Hospital implemented a double-checking system for all transplantations. According to the Institute of Medicine, as many as 44,000 to 98,000 people die in U.S. hospitals each year as the result of medical errors. To remove mistakes in the transplant process, communication between medical staff and administration must be clear and structured.
Technology has become a key tool in this effort. Electronic Health Records (EHR) systems provide a significant advance by facilitating "a new level of transparency and information sharing among care teams about an individual's care" (Duke Medicine, 2013). When a patient is on the transplant list and their name comes up for a match, paperwork entered into the electronic health record contains all their medical history. This information is double-checked prior to surgery by each surgeon and nurse involved in the procedure, which lessens the chances of the patient receiving the wrong organs before surgery begins.
Additional protocols now require that when an organ is being picked up from its location, the personnel collecting it must double-check the blood type with two staff members from the transplant location and obtain their signatures as proof. Once these protocols are in effect, administration must ensure the department follows this approach and implements any additional changes needed to maintain patient safety.
Stakeholders are significant in healthcare. Great leaders are in tune with their stakeholders by being attentive to the barriers that interfere with communication (Burns, Bradley, & Weiner, 2011). Since many stakeholders were affected by Jessica's death, each stakeholder communication strategy must be different.
"CEO strategies for addressing families, media, and the medical community"
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