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About My Error
An orthopod talks candidly about wrong-site surgery
David Ring
Publish Date: May 22, 2014
OR Excellence
David Ring, MD, PhD David Ring, MD, PhD

Speaker Profile

  • Presented his error as a case conference that was eventually published in the New England Journal of Medicine.
  • After the publication, he went on the "wrong procedure world tour."
  • Associate professor of orthopedic surgery, Harvard Medical School.

The 65-year-old woman came to the day surgery unit at Massachusetts General Hospital in Boston for an elective trigger-finger release. It was a procedure orthopedic surgeon David Ring, MD, PhD, had performed hundreds of times. What could go wrong? Plenty, it turns out. In "The Worst Error of My Career," orthopedic surgeon Dr. Ring will discuss exactly why he performed a carpal tunnel release instead. As he told us, the lessons are in the telling.

  • Stress levels were high. It was the end of a busy day, and she was my last patient — one of 3 hand cases scheduled after larger procedures. Mentally, I had prepared to perform the more complex cases followed by carpal tunnels. The surgical schedule was backed up and one of my previous patients who'd been nervous about receiving local anesthesia needed additional comforting in recovery. Stress levels were high and the case in question was moved to another OR. The nurse who completed the pre-op assessment did not follow the patient to the new room.
  • The moment he knew. I realized my error about 15 minutes after the surgery, and immediately informed the patient. She consented to having me perform the trigger-finger release, which went off without incident. The patient was discharged the same day. I apologized to her and her son during numerous follow-up phone calls. The hospital waived all fees and reached a financial settlement with the patient. Other than an unnecessary incision on the palm, there was no lasting harm for my patient.
  • A cascade of errors. Poor scheduling and inadequate staffing levels caused last-minute changes that added to an already stressful day. The correct wrist was marked, but the incision site on the left index finger wasn't. Plus, the marking was wiped off during the skin prepping. I could communicate with the patient in Spanish, but we should have used an interpreter to keep the entire surgical team informed. There were more oversights that culminated in error, which I'll discuss in detail at the conference.
  • Didn't you perform a time out? No. When the error occurred, hospital policy called for pre-op time outs, but the process wasn't standardized and safety checks often occurred before the patient entered the OR. Now, time outs occur just before the incision is made, with every member of the surgical team in the room, paying attention and actively participating. Everyone is empowered and encouraged to speak up if something seems amiss.
  • On sharing his story. We need to be open and honest about the mistakes we make, and about how well the systems we have in place to protect patients actually work in practice. Discussing the breakdowns that lead to surgical errors is the only way to learn from what went wrong and make needed improvements. It shouldn't be about placing or deflecting blame. The sooner we realize that everyone will make mistakes at some point in their surgical careers, we can move away from holding people accountable to unrealistic expectations of being perfect. It'll take a culture change to build and champion a system that replaces blame and shame with a sincere desire to drill down to why errors happened, in order to make changes that let us operate as safely as possible. Health care is getting better at turning errors into opportunities for significant change, but we have a ways to go.

Ultimately, I want attendees to realize that the protocols put in place to protect patients aren't burdens. They're there to help us do our jobs more safely, to ensure wrong-site surgery never happens. I tell my story so others don't experience what I went through and what my patient endured.

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