According to the case present on Jesica Santillon, the transplant process involves multiple steps from obtaining the accurate patient information in order to begin the process of finding suitable organs to post-op and the intensive care unit stay during the recovery stage (Burns, Bradley, and Weiner, 2011). Many individuals and hand-offs are involved throughout the transplant process, increasing the risk of losing important information at each transition point, which was a contributing factor in the Jesica Santillon tragedy. Jesica’s blood type was corrected noted as O on the patient chart. Due to there being so many individuals involved and no clear communication as to what was needed, an organ was acquired that was blood type A and a mismatch for the patient.…show more content… Jaggers in regards to the requirements of the organs occurred. The staff at Carolina Donor Services stated that they informed Dr. Jaggers that the organs were blood type A, but Dr. Jaggers stated that he did not recall the details of this conversation. A physician that was not entirely informed about Jesica’s case and Jesica’s blood type was responsible for picking up the organs. It was stated that this physician was informed multiple times that the organs were A blood type, but since this physician was not informed and/or familiar with Jesica’s case and blood type, he did not realize there was a patient/organ mismatch. There are clearly others steps that were looked over after the organs arrived, otherwise the mismatch would have been caught before the organs were implanted in Jesica’s body. Errors occurred during Jesica’s transplant process resulting in Duke Medical Center and the physician answering to Jesica’s family, their lawyers, the press, the community, and the community of other healthcare providers (Burns, Bradley, and Weiner,