Big Mistake in Operating Room, Patient Dead

[BillTre]

The patent in Russia being operated on for ovarian cysts had a formalin (37% formaldehyde solution) mistakenly introduced into her abdomen.
It was washed out when the mistake was recognized, but ultimately, too late.

Formaldehyde is used for many things, in biology it is often used to fix tissues. It covalently bonds to nitrogen in proteins, either drastically altering their structure of double bonding with adjacent proteins. This causes the proteins to become denatured, non-functional, and precipitate (fixing their location, thus fixing the protein, ). It results in dead cells.

This reminds me of a similar (difficult to forget) story I read about long ago when I was in graduate school. In this case, gluteraldehyde (a stronger, better cross linker than formaldehyde, good for doing histology) was put into someone's brain and fixed their brain while leaving the rest of the body OK (with mechanical assistance).

 

[DaveC426913]

Link to article?

 

[BillTre]

Didn't work for some reason.
Here it is.

 

[Choppy]

It's always sad to hear about medical mistakes.

One thing I've noticed in recent years, at least in my neck of the woods, is a shift towards a culture of learning from mistakes like this - investigations with attempts to identify root causes and ultimately improve processes. I mean, I'm sure that's always been there to one extent or another, but sometimes with situations like this people can instinctively start to look for someone to blame and miss opportunities to revise their system.

 

[BillTre]

Like only put fixatives in specially colored containers in the OR?