Last November 18 marked the kickoff of Duke University Medical Center's first Patient Safety Week. Posters went up. Patients filled in cards, detailing their medical conditions and medications. The staff was instructed on how to report safety-related problems. Everyone was upbeat. Duke was taking concrete steps to deal with the growing national problem of preventable hospital errors. Less than three months later, 17-year-old Jesica Santillan was dead, the victim of an elementary and inexcusable medical mistake: Her heart-lung transplant had gone wrong because her blood type and the donor's did not match. The tragedy grabbed the national imagination, because Jesica's parents had been told of miracles performed at Duke and had risked illegally crossing the Mexican border to bring her to one of the world's leading transplant centers.

The blame fell most heavily on the surgeon, James Jaggers. He didn't check Jesica's blood type when he made the request for the heart and lungs he stitched into her frail body less than 24 hours later. Duke took heat as well for failing to notice the mishap and save the surgeon from his fatal error. Jaggers didn't duck responsibility. "As Jesica's surgeon," he said, his face a study in misery on a videotaped statement released the day of Jesica's death, "I am ultimately responsible."

The culture of medicine dictates that the surgeon, as commanding officer of the operating room, take the fall when a patient is injured or killed. Jaggers blundered badly, and Duke failed to catch him. "We didn't have enough checks," Ralph Snyderman, Duke University Medical Center & Health System's chief executive, says flatly.

Basic flaws. An investigation by U.S. News yields a different conclusion, one with more far-reaching, and frightening, implications. Jesica Santillan's death, on February 22, was clearly due to surgeon and hospital error, but the entire national organ-transplant system also played a major role. The same process that found Jesica a heart and lungs and moved them to the operating room failed to protect her. Jesica's tragic death made headlines. But there have been other cases, many unreported, of accidentally mismatched organs. Given the basic flaws in the system exposed by Jesica's story, it's remarkable that there have not been more deaths.

The tale begins with Jesica's birth in Guzman, a small city in western Mexico, on Dec. 26, 1985. As a child, Yesica (she Americanized her name when she came to the United States) lacked stamina. As she grew older, she tired more and more easily. When she was about 5, doctors in Guadalajara told her mother, Magdalena Santillan, that Jesica would need a heart transplant, although they did not correctly diagnose the little girl's condition. They advised her mother to take her daughter to the United States.

And so she did. In March 1999, Jesica and her mother, along with her stepfather and a younger sister and brother, crossed the U.S.-Mexican border on foot--without the help of "coyotes," who charge illegal aliens large sums to smuggle them into the United States. Their destination was Duke. Magdalena had heard from a sister, who according to a family friend had also entered the country illegally and was working in the North Carolina tobacco fields, about the Children's Miracle Network. Duke was among the affiliation of 170 hospitals committed to providing charity care for sick children. Magdalena's sister was sure Duke would help Jesica.

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