Neurosurgeon, Steven Hwang, made a medial error that affected a 74-year-old female patient, Caroline Carcerano. The patient went in for what should have been a “routine” procedure to insert an implantable pain pump. The surgeon asked for a dye called Omnipaque, but the pharmacy did not have it and provided a different dye. The dye received by the nurse was MD-76. The surgeon was told by the nurse “this is what we have” after the OR pharmacy informed her that they did not carry Omnipaque. MD-76 came with a warning label reading, “not for intrathecal
