Organizational Change in the Face of Highly Public Errors II. The Duke Experience
In February 2003, 17-year-old Jessica Santillan died at Duke University Medical Center due to a mismatched heart-lung transplantation. As with the Dana-Farber experience, the death made headlines around the world and devastated the leaders and providers at Duke, one of the world's preeminent academic medical centers. We asked Dr. Karen Frush, a pediatrician who became Duke's Chief Patient Safety Officer in November 2004, to describe the impact of this case and the changes it engendered.