(Received 15 September 1997; accepted 25 February 1998)
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A 64-year-old diabetic man underwent total maxillectomy with orbital exenteration because of recurrent carcinoma. In order to decrease pressure at the surgical site, 50 mL of cerebrospinal fluid were withdrawn. After the procedure was completed, 5% glutaraldehyde was inadvertently injected into the subarachnoid space instead of reinjection of the original cerebrospinal fluid. The patient suffered hypotension and coma culminating in death five days after the procedure. Postmortem examination revealed exquisite fixation of the outer cortical shell of the spinal cord and brain stem. The mishap occurred because an unlabeled vial was mistaken for the withdrawn cerebrospinal fluid. Graicunas' theory and formula on relationship complexities in organizations is exemplified by this occurrence. One may calculate the theoretical potential for 24,708 miscommunications during such a complex and lengthy surgical procedure. Proper operating room procedures must be developed and followed in order to prevent such tragedies.
Chief medical examiner (retired), Miami-Dade County Medical Examiner Department, and professor of pathology emeritus, University of Miami School of Medicine, Miami, FL
Chief medical examiner, Miami-Dade County Medical Examiner Department, and clinical associate professor of pathology, University of Miami School of Medicine, Miami, FL
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