Doctors at St. Joseph’s Hospital Health Center in New York were removing a woman’s organs for transplant when they realised the woman was alive. Colleen S. Burns opened her eyes during surgery.
The care of patient Burns was criticised by the state Health Department. In September 2012 St. Joseph’s Hospital was fined $22,000. Of that amount, $6,000 was for the Burns patient, the remainder was for an incident that occurred in 2011. Along with the fine, the hospital was ordered to hire a consulting neurologist who would teach the hospital staff how to accurately diagnose brain death.
The state Health Department review found these mistakes:
Staff skipped a recommended treatment to prevent the drugs the patient took from being absorbed by her stomach and intestines.
Not enough testing was done to see if she was free of all drugs.
Not enough brain scans were performed.
Doctors ignored a nurse’s observations indicating Burns was not dead and her condition was improving.
Burns’ mother Lucille Kuss explained how the experience affected the family:
The doctors never explained what went wrong. They were just kind of shocked themselves. It came as a surprise to them as well.
When the incident occurred in 2009, St. Joseph hospital officials thought Burns had a “cardiac death” from a drug overdose. The family had agreed to switch off life support and gave doctors permission to remove her organs to be donated. The day prior to the removal of her organs, a nurse did a reflex test by scratching her finger across the bottom of Burns’ foot. The nurse noticed her toes curled, a dead person would not react to this.
According to doctors, Burns had suffered irreversible brain damage. But in the preparation area of the operating room, her nostrils flared. While in theatre it appeared she may have been breathing independently from the respirator. The records show that despite the nurse’s observations, Burns was given a sedative.
The doctor had also failed to detail these findings in his notes. Burns was wheeled into the operating room to have her organs harvested and only when she opened her eyes was the surgery called off.
Burns’ irreversible brain damage had been misdiagnosed, she was in fact in a deep coma according to the state Health Department.
The federal Centers for Medicare and Medicaid Services responded to the incident.
Despite this sequence of events, intensive objective peer review and root cause analysis of the case was not done by the hospital’s quality assurance program until prompted by the Department of Health.
The hospital did not undertake an intensive and critical review of the near catastrophic event in this case [and officials did not] identify the inadequate physician evaluations of (Burns) that occurred when nursing staff questioned possible signs of improving neurological function.
Dr Meyer, a general vascular surgeon and an associate professor of clinical surgery at New York Medical College, was confused by why sedatives were used. Meyer said:
It would sedate her to the point that she would be non-reactive. If you have to sedate them or give them pain medication, they’re not brain dead and you shouldn’t be harvesting their organs.
Burns recovered from her drug overdose of Xanax, Benadryl and a muscle relaxant. She was discharged from hospital two weeks later. Sadly only 16 months after leaving the hospital she committed suicide.
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