Doctors at St. Joseph's hospital in Central New York were in the process of starting surgery to harvest a dead woman's organs when that woman opened her eyes. She was still alive.
That massive mistake has now cost the hospital $6,000 after a federal inquiry in addition to another fine of $16,000 after another patient fell and injured her head when she was left unattended in 2011, according to reporting in the Syracuse Post-Standard.
Colleen S. Burns of North Syracuse, New York, 41, had been admitted to the hospital in October 2009 for a drug overdose.
Because of a series of mistakes in evaluation, doctors believed that the woman was dead and started the organ donation process.
The state Health Department investigation of the incident found that when Burns was first admitted, they skipped a recommended treatment that would prevent the drugs she had taken - Xanax, Benadryl and a muscle relaxant - from being absorbed by her stomach and intestines.
They also didn't do enough testing to see if she was free of drugs or perform enough brain scans.
Because they didn't perform enough of these scans, doctors believed that Burns was brain dead, when in reality the over dose had put her in a coma.
After doctors said she was essentially brain dead, her family agreed to take her off life support and her organs donated.
But the day before the organs were to be removed, a nurse performed a reflex test and found that Burns was still reacting.
She scraped her finger on the bottom of one of Burns' feet and her toes curled downward, a sign that she was still alive.
And that wasn't the only sign of life. As she was being wheeled to the operating room, Burns' nostrils flared and it seemed she was breathing independently from the respirator. Her lips and tongue were moving as well.
But doctor's ignored the nurse's observations which indicated Burns was still alive, and proceeded with the surgery anyway.
Mistakes: A federal report found that hospital officials didn't perform enough tests to accurately access if Burns was brain dead
Before the procedure, Burns was given an injection of the sedative Ativan, but neither the sedative or the observations of life were recorded in the doctor's notes for the procedure.
Dr. David Mayer, a general vascular surgeon and associate professor of clinical surgery an New York Medical College, said the application of a sedative is quite strange.
'It would sedate her to the point that she could be non-reactive,' Mayer told the Post-Standard. 'If you have to sedate them or give them pain medication, they're not brain dead and you shouldn't be harvesting their organs.'
It wasn't until Burns opened her eyes in the OR that the procedure was called off.
Neither Burns or her family sued the hospital for malpractice. Sixteen months later, a determined Burns successfully committed suicide.
Her mother, Lucille Kuss said her daughter wasn't upset about the incident.
'She was so depressed that it really didn't make any difference to her,' Kuss said.
It did, however, make a difference for the state Health Department and the Centers for Medicare and Medicaid Services. Both investigated the incident and found St. Joe's procedures lacking.
The hospital didn't even report the incident, nor conduct an investigation of their own.
It wasn't until after the Post-Standard started their investigation that the hospital put out any sort of explanation for what happened.
According to the federal report: 'The hospital did not undertake an intensive and critical review of the near catastrophic event in this case.'
The officials at the hospital did not 'identify the inadequate physician evaluations of (Burns) that occurred when nursing staff questioned possible signs of improving neurological function.'
Overall, the federal report found that the patient did not meet criteria for withdrawal of care.
The spokesman for the hospital said that they've learned from the experience and 'have modified our policies to include the type of unusual circumstance presented in this case.'
In addition to the total $22,000 fine, the hospital was ordered to hire a consultant to review the hospital's quality assurance program, implement the consultants recommendations and hire a consulting neurologist to teach staff how to accurately diagnose brain death.