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The Syracuse Post-Standard recently uncovered a report from the US Department of Health and Human Services (HHS) that described a series of errors by medical staff at St. Joseph’s Hospital Health Center that almost resulted in the removal of organs in a patient they thought was dead, but who was actually still alive.

The near tragedy occurred in 2009. The patient, a 41 year old Syracuse woman, was rushed to the emergency room after overdosing on Xanax, Benadryl, muscle relaxant and an anti-inflammatory drug. Colleen Burns was unresponsive, with a weak pulse and low body temperature when she was admitted into the hospital. She was immediately put on a ventilator. Poison control specialists advised doctors treating the patient to use activated charcoal to stop Burns’ body from absorbing the drugs, but it was never implemented. Then she began having seizures. However, two head scans revealed no abnormal activity.

Doctors diagnosed the victim with irreversible brain damage, despite reports from nurses her condition appeared to be improving. Documentation of Burns’ improvement included curling her toes when touched, flaring her nostrils and moving her lips and tongue. And although she was connected to a respirator, she was breathing on her own.

Despite these signs, doctors told Burns’ family she had suffered “cardiac death” and they agreed to have her removed from life support and remove her organs for donation.

Burns was taken into an operating room, and as doctors prepared the organ-harvesting procedure, she opened her eyes. Doctors immediately canceled the procedure.

The HHS concluded that Burns had been in a deep coma from the drug overdose and that medical staff misread that as irreversible brain damage without doing enough to evaluate her condition. And the agency was also critical of the hospital’s response after the incident. It wasn’t until the day after the state began investigating the case six months later that the hospital looked into what happened.

“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 federal agency’s report said.

The state fined St. Joseph’s $22,000 and ordered the Syracuse facility to hire a consultant to review the hospital’s quality assurance program and implement the consultant’s recommendations. They were also ordered to hire a consulting neurologist to teach staff how to accurately diagnose brain death.

Sadly, Collen Burns committed suicide in January, 2011.

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