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St. Joseph's Hospital Health Center

(Paul Finch)

Kathryn Ruscitto, president and CEO of St. Joseph's Hospital Health Center

Syracuse, N.Y. -- The top executive of St. Joseph's Hospital Health Center says the hospital has overhauled the way it provides care since a near catastrophe four years ago when its doctors almost removed organs from a patient they mistakenly thought was dead.

Kathryn Ruscitto, president and CEO of St. Joe's, wrote about the incident on the hospital's website Monday after syracuse.com and The Post-Standard published a report on the case Sunday.

The 2009 incident involved a 41-year-old North Syracuse woman who was brought to the hospital's emergency room after overdosing on drugs. Doctors believed she had experienced irreversible brain damage and cardiac death. Her family agreed to allow doctors to withdraw life support and remove her organs for transplant after they were told she was dead.

After she was moved to an operating room, the patient opened her eyes and looked at the lights above. At that point, the organ harvesting process was called off.

It turned out the woman had been in a deep coma from the drug overdose.

An investigation by the state Health Department found doctors ignored a nurse's observations indicating the patient was not dead and her condition was improving. That was one in a series of mistakes that led to the near miss, investigators found. The investigation also faulted St. Joe's for not doing a thorough review of the incident until it was prodded by state regulators.

Ruscitto said the hospital agreed not to discuss details of the event at the family's request.

But in her blog post, Ruscitto described some of the changes made in the wake of the incident.

"In this case, we have made personnel and policy changes and re-examined everything we do related to quality," she wrote.

Over the last four years the hospital has worked with a nationally recognized quality institute to redesign its approach to patient care, according to Ruscitto. The hospital has reexamined every aspect of its quality process and added every tool recommended and utilized by the highest performing hospitals, she noted.

"We now provide quality education at every management meeting, and have set up a process to report not just errors - but near misses - so we can identify and fix problems before they occur," she wrote.

The hospital also started mandatory training focusing on accountability and the need for staff to be sure they are doing all they can for patient safety and care, Ruscitto wrote.

"We never want patients to be fearful of their healthcare experience," Ruscitto wrote. "They need to know how deeply our employees feel when we do make a mistake and how open and honest we are with ourselves in making sure it doesn't happen again."