Colleen Burns had been taken to St. Joseph's Hospital Health Centre in Syracuse after taking a drug overdose in 2009. She was thought to have passed away, a victim of "cardiac death", and so her family agreed to turn off the 41-year-old's life support machine and donate her organs.
It was not until she was wheeled into the operating theatre and opened her eyes in response to the lights that doctors called off the procedure.
Lucille Kuss, Ms Burns' mother, told Syracuse's The Post-Standard newspaper that the doctors never explained what went wrong.
"They were just kind of shocked themselves," she said. "It came as a surprise to them as well."
Ms Burns, a mother of three, was discharged from the hospital a fortnight after the operation, but committed suicide less than two years later.
"She was so depressed that it really didn't make any difference to her," said her mother.
The family did not sue but the hospital was fined $6,000 (£4,000) by the state health department in September – the case only came to light after the newspaper made requests through the Freedom of Information Act.
"These sorts of things do happen," said Lisa McGiffert, director of Consumers Union Safe Patient Project. "It's pretty disturbing."
Mrs McGiffert said there is no way of knowing how often near-catastrophes like the Burns case happen because in the US there is no system in place to collect information from hospitals about medical errors.
The state started investigating the case in March 2010 in response to an inquiry from The Post-Standard.
The investigation revealed a catalogue of errors in the handling of Ms Burns' case.
The drugs overdose had sent her into a deep coma, the state health department found, and hospital personnel misread that as irreversible brain damage without doing enough to evaluate her condition.
Furthermore, the day before her organs were to be removed, a nurse had performed a reflex test – scraping a finger on the bottom of her foot. The toes curled downward – not the expected reaction of someone who's supposed to be dead.
Outside the operating theatre, her nostrils appeared to show signs of breathing, and her lips and tongue moved.
"Dead people don't curl their toes," said Dr Charles Wetli, a forensic pathologist from New Jersey. "And they don't fight against the respirator and want to breathe on their own."
Twenty minutes after those observations were made, a nurse gave Burns an injection of the sedative Ativan, according to records.
In the doctors' notes, there's no mention of the sedative or any indication they were aware of her improving condition.
"If you have to sedate them or give them pain medication, they're not brain-dead and you shouldn't be harvesting their organs," said Dr David Mayer, a surgeon and an associate professor of clinical surgery at New York Medical College.
St. Joseph's submitted a plan to correct problems identified in the investigation to the state health department in August 2011.
The state fined St. Joseph's and ordered it to hire a consultant to review the hospital's quality assurance program and implement the consultant's recommendations.
The hospital also was ordered to hire a consulting neurologist to teach staff how to accurately diagnose brain death.
Kerri Howell, spokeswoman for the hospital, told the newspaper: "St. Joseph's goal is to provide the highest quality of care to every patient, every time.
"These policies were followed in this case, which was complicated in terms of care and diagnosis.
"We've learned from this experience and have modified our policies to include the type of unusual circumstance presented in this case."
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