Cryopreserved tendon discarded due to DMSO odor unrecognized by surgeon

Record number: 
Adverse Occurrence type: 
MPHO Type: 
Alerting signals, symptoms, evidence of occurrence: 
Surgeon did not read the package insert and was unaware of DMSO odor. Delay in surgery and loss of graft
Demonstration of imputability or root cause: 
Tissue Bank informed of discard
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