A $5.1 million malpractice verdict resulting from a Pennsylvania ASC's medication mix-up offers an undisputable lesson for surgical safety. Specifically: Always label your meds.

The patient, Jacqueline DiTore, was undergoing sinus surgery at the Abington Surgical Center in June 2010. The surgeon, Warren Zager, MD, had ordered the injection of lidocaine with epinephrine into her septum as a local anesthetic. But an OR nurse inadvertently drew up the nasal decongestant Afrin into the syringe that she handed him.

How did this happen? According to a published account of the error and its outcomes, Dr. Zager intended to use the decongestant to control bleeding during the case. After one nurse poured it into an unlabeled basin, planning to soak cotton balls in it, another nurse mistook the basin's contents and filled a syringe.

After the injection, Ms. DiTore's heart rate dropped precipitously. The anesthesiologist delivered a rescue medication, after which Dr. Zager realized the error. Deciding to continue with the surgery, he injected the lidocaine, at which point the patient's heart rate and blood pressure spiked and, despite the surgical team's efforts, she suffered cardiac arrest.

While she survived and was transported to a nearby hospital, the oxygen deprivation and cardiac damage left her with impaired vision, speech, memory, balance and other symptoms of brain damage, according to her medical malpractice lawsuit.

Dr. Zager and the surgery center denied liability, placing the blame on other surgical personnel who'd participated in the surgery, and who had been dismissed from the lawsuit before the trial. They argued that Ms. DiTore had made a full recovery and "was restricted only by limitations she has imposed on herself."

A jury, however, awarded Ms. DiTore $4.6 million in damages and her husband $500,000 for loss of companionship in January 2014, having found the surgery center 61.5% liable and Dr. Zager 38.5% liable.

An attorney for the DiTores, Dr. Zager, and representatives of Abington Surgical Center did not immediately return calls seeking comment.

David Bernard