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.

Malpractice: St. Joseph’s hospital in Central New York  almost harvested a live woman’s organs in 2009

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.

Read more: DailyMail