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State Medical Board Issues ‘Letter of Concern’ in Heart Mismatch

January 14, 1988

TUCSON, Ariz. (AP) _ The Arizona Board of Medical Examiners has mildly reprimanded two University Medical Center cardiovascular surgeons over an error that led to the transplant of a mismatched donor heart.

The medical board issued an advisory ″letter of concern″ Wednesday, the mildest form of reprimand it can issue.

Associate Executive Director David Landrith said the board found ″no hard and fast negligence″ by Drs. Timothy Icenogle and Jack G. Copeland in the incident last April 21 involving patient James J. Shocklee.

Two days after the error, Copeland, chief of cardiothoracic surgery at the center, attributed the mismatch to ″human error.″

The state board did not single out one person for the mismatch, and Copeland, who was not involved in the original surgery, never has identified the responsible party.

Although the board had found no cause to take action against the surgeons’ licenses, Landrith said, the mistake was worth acknowledging formally.

″We always acknowledged that the ultimate responsibility for the heart transplant team relies within the cardiac surgeons,″ Icenogle said Thursday, adding that the board’s action did not surprise the surgical team.

Icenogle transplanted a heart later found to be of the wrong blood type in the 39-year-old patient, and Shocklee began rejecting the organ shortly after surgery.

Icenogle and Copeland replaced the original donor heart with a Jarvik artificial heart for 12 days until a properly matched second donor heart could be transplanted.

Federal officials subsquently investigated the incident and examined the transplant program’s procedures and quality assurance provisions.

They concluded it was an isolated incident that did not jeopardize the center’s Medicare funding, and the heart transplant team implemented new safety checking procedures designed to prevent a recurrence.

Board chairman Dr. Michael Geyser said, ″It only proves what the medical profession has been saying for years. Most errors are made by competent people who err because they are human. No matter how good your system, there is going to be mistakes.″

Shocklee, now 40, recovered after the second transplant and has returned to his home in Scottsdale and resumed working as a liquor and wine sales manager.

Copeland said Shocklee, whom he examined on a clinical visit Wednesday in Phoenix, was ″doing great. He won two prizes over the holidays for selling booze - he won a free trip to San Francisco and a free trip to Hawaii, so he must be doing fairly well.″

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