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Caroline Carcerano underwent spinal surgery at Tufts Medical Center in Boston in hopes that the procedure would resolve pain from a back injury. During the procedure, her neurosurgeon requested a special dye to test the location of tubing threaded into her spine.
The pharmacy did not have the dye requested by the neurosurgeon, so it sent a different one, hospital leaders confirmed in statements released since the incident in November 2013. When an operating room nurse handed him the dye, the neurosurgeon checked the label but did not see that the label was for a different dye and that the label specifically said "not for intrathecal use,’’ warning against using it in the spine, according to Medicare investigators.
That warning was unheeded because the surgeon "saw" what he anticipated the label would say: the name of the correct dye, says Tufts Chief Medical Officer Saul Weingart, MD, MPP, PhD. The OR scene was dynamic, and all team members were busy because the procedure was technically challenging, he says. "He asked for the contrast, looked at it, and he doesn’t exactly recall what he saw, but it seemed to be what he thought it was. And off he went," Weingart says.
The patient died the next day from the effects of the spinal injection. Carcerano’s sons filed a malpractice lawsuit against in June 2014 against Tufts and 12 pharmacists, nurses, and surgeons.