The patient was nervous about the local anesthesia injection before it was administered, and her distress continued to escalate when she was moved to the recovery area after her carpal tunnel release surgery. The woman's surgeon, David C. Ring, MD, tried to ease her anxiety. "She was really, really upset, traumatized just kind of falling apart," he recalls. She eventually calmed down, but the scene unnerved Dr. Ring and left him determined to do better as he headed back into the OR for the next procedure. "I had the resolve, when I left her in recovery, to make my next surgery the best carpal tunnel release ever." Except his next surgery wasn't supposed to be a carpal tunnel release.

To Err Is Human is the title of the seminal 1999 consensus report from the Institute of Medicine that sought to define "a comprehensive strategy by which government, healthcare providers, industry and consumers can reduce preventable medical errors." More than 10 years later, these errors still persist. A study published in the Archives of Surgery last year found "a persisting high frequency of surgical 'never events,'" such as wrong-procedure and wrong-site surgery, 7 years after the Joint Commission instituted its 3-pronged Universal Protocol of pre-procedure verification, site marking and time out. The Joint Commission estimates that there are about 40 wrong-site surgical errors a week in the United States.

A lot of holes in the cheese
The question on everyone's minds — the victims and their family members, the clinicians and surgical facilities, the lawyers and regulators — is "Why?" In this era of checklists and quality reporting and malpractice litigation, why do these mistakes keep happening? The answer, as Dr. Ring's story illustrates, is complicated.

For all the things that could — and did — go wrong leading up to the moment when Dr. Ring made the incision to perform carpal tunnel surgery on a 65-year-old woman who was supposed to undergo a trigger finger release, the one that sticks out most vividly in the hand surgeon's mind is something that was largely out of his control. "The No. 1 thing was that earlier patient," he said in a phone interview, referring to the woman who'd become agitated in the recovery area of Massachusetts General Hospital's day-surgery unit.

While that event may have tipped the balance, a closer examination of the day's events, which Dr. Ring shared in stark detail in the pages of the New England Journal of Medicine last November, reveals a confluence of mishaps and miscommunication. It's an almost perfect illustration of the Swiss cheese model of systemic failure: Think of multiple slices of Swiss cheese lined up, each hole representing an opportunity for error or failure in that particular layer of the system. If the holes align with no intervening layer of cheese, the error passes through.

"There were a lot of holes in the cheese that day," says Dr. Ring — some unavoidable, many preventable.

Flawed site-marking protocol
The hospital's surgical site-marking protocols at the time didn't match the most recent version of the Joint Commission's Universal Protocol. Following what was then Mass General's policy, the nurse who performed the pre-operative assessment on the trigger finger patient correctly marked the patient's left arm at the wrist, according to Dr. Ring's account. However, the nurse didn't specifically mark the planned incision site on the patient's left hand, and the marker used wasn't strong enough to withstand washing with soap, alcohol and povidone-iodine. When the surgical site was prepped with these agents in the OR, the mark was wiped away.

The Universal Protocol, most recently updated in 2009, calls for a "licensed independent practitioner who is ultimately accountable for the procedure and will be present when the procedure is performed" to mark the site. This person, usually the surgeon, should delegate this task only in "limited circumstances," says the Joint Commission. In the case of Dr. Ring's trigger finger patient, the nurse who marked the site wasn't present for the actual procedure due to a last-minute scheduling change. Now, hospital policy calls for the surgeon to mark the surgical site, with input and verification from the patient when possible. Mass General has also discontinued the use of alcohol-based skin preps that can erase site markings, says Peter Dunn, MD, executive director for the operating rooms, in the NEJM report.

One change not specifically recommended by the Joint Commission or adopted by Mass General, but which Dr. Ring endorses for orthopedic and hand surgeons, is to have the surgeon sign his initials directly on the site of the planned incision. "Operate Through Your Initials," an initiative the Canadian Orthopaedic Association devised in the 1990s, led to a steady decline in wrong-site surgeries there. The American Academy of Orthopaedic Surgeons followed that effort with the similar "Sign Your Site" campaign. "You've got to have the mark right where you're going to cut," says Dr. Ring. "It should be where the knife goes, like a bull's-eye."

Scheduling and shift changes
Dr. Ring says that the stress level in Mass General's day-surgery unit was high on the day of his error due to a packed schedule and delays involving several surgeons. Gregg S. Meyer, MD, senior vice president for quality and safety at Mass General, calls them "latent errors" — "problems in the scheduling and deployment of personnel that delayed and then interrupted the procedure and distracted the surgeon."

• Lack of interpreter. The Spanish-speaking trigger finger patient required the use of an interpreter, but none was available. Since he speaks the language, Dr. Ring had to step into the role of interpreter. This led to a misunderstanding in the operating room, as the circulating nurse mistook a conversation Dr. Ring was having with the patient in Spanish for the time out, which was never performed.
• Room change. The trigger finger release was Dr. Ring's last procedure of the day. Because of delays, it was moved to a different OR. The change in location meant a change in personnel, removing the nurse who'd done the pre-op assessment from the team assigned to the case. The new room also lacked a tourniquet, which required the circulating nurse to leave the room during pre-procedure preparations, distracting her from the patient and her documentation duties.
• Mid-procedure staffing change. Carpal tunnel release is a relatively quick surgical procedure, but because it took place right around a 3 p.m. shift change, the nursing team on the case changed in the middle of the procedure. "Anytime there's a staff change during a case, you're distracted, handing things over, your eyes aren't on the field and you're not thinking about what the surgeon's doing," says Dr. Ring.

The time out that didn't happen
Per the Universal Protocol, Mass General's policy at the time of Dr. Ring's error was to perform a pre-operative time out, but this procedure often took place before the patient was washed and prepped for surgery, sometimes even before the patient arrived in the OR, says Dr. Ring. Under the old policy, one could see how the circulating nurse — who was already distracted — could mistake a conversation in Spanish between surgeon and patient in the OR for the time out.

No more, says Dr. Ring. Now Mass General follows the World Health Organization's surgical safety checklist protocols, which include a pre-op huddle among the surgical team before the patient enters the room to go over the basics (patient, procedure, preparation). The official time out is now a "hard stop" that occurs just before the first incision, explains Dr. Ring. "Everybody looks up, pays attention, makes sure you're doing the right thing. You don't get the knife until the time out is completed and everyone agrees." This process involves all team members: surgeon, nursing staff, techs and anesthesia, and everyone is encouraged to speak up and request a do-over if they feel there's any confusion or discrepancy. "It's much, much better and safer than what we were doing before," says Dr. Ring. At the end of the case, the surgical team stops again for a brief post-procedure huddle to go over how it went.

After the error: What happened next?
About 15 minutes after he completed his carpal tunnel release on the 65-year-old woman, Dr. Ring realized his error: She was supposed to have had a trigger finger release. He immediately informed the staff of the mistake and personally apologized to his patient. With her consent, Dr. Ring performed the trigger finger release without complication; the woman went home that day.

"I filed a safety report and notified the hospital's risk manager of the error and the rectification," Dr. Ring told the NEJM. He followed up with the patient by phone and helped with some of her post-op care, but several days later the patient's son said that his mother had lost faith in his abilities and wouldn't return to his care. Mass General waived all charges for the surgery and eventually reached a financial settlement with the patient.

Although Dr. Ring says he knew publishing the NEJM article detailing what had happened was "the right thing to do," that it would help patients, surgeons and healthcare institutions, he also knew it opened him up to the possibility that other patients wouldn't want to come to him for surgery or that doctors would stop referring patients to him. But "the response has been overwhelmingly positive," he says. "It means a lot to me. I hope it will embolden other people to talk about their mistakes."

Dr. Ring recalls sitting in on a general aviation course, listening to pilots discuss private plane crashes that had resulted in death. "They were very open about the fact that they weren't perfect, that they needed to have systems to keep them safe. I couldn't believe how many people came up and told stories and were open to the discussion of error," he says. "Medicine is getting better at that. It's good to see."

In exploring the many breakdowns that led to his surgical error, Dr. Ring says he's not interested in playing the blame game. "Blame and shame is the old school." So is believing that clinicians have the capacity for perfection. "The new way to look at it is, you will make mistakes," says Dr. Ring. "The way that you are held accountable is not to be perfect, but to really support and build and champion the system that will help you do things as well and safely as possible." It requires a culture change, which Dr. Ring acknowledges can be difficult to achieve. "We are sometimes willfully blind to our capacity for error — ashamed of it, even though we shouldn't be," he says. "People should be more aware of the need for systems and teams, of mindfulness and awareness to limit the capacity for error to make imperfections into opportunities."