Last week, the Dean Health System announced it would lay off 90 employees. Normally, that would have been the end of it.

However, it seems that a Dean Health System manager, instructed to lay off a nurse “immediately,” did so — by marching into a surgical theater during a procedure and firing her.

Although it was a minor surgical procedure, the instant layoff violated medical protocol. Dean Health System says the error in judgment posed no danger to the patient.

The company declined to name the employees involved, or what type of procedure was interrupted.

The layoffs focused primarily on non-patient-care positions. The terminated employees were given severance packages and outplacement.

Dean Health System is 95% owned by physician shareholders; the remaining 5% is owned by St. Louis, Missouri’s SSM Health Care.