I have seen several media outlets discussing Dr. David Ring……some attacking him for his mistake and others calling him a noble hero. I think he has provided a great service in explaining his mistakes, and deserves a special thank you on this day of Thanksgiving! See articles here and here.
Dr. David C. Ring, a hand and arm surgeon at Massachusetts General Hospital, described in the latest issue of the New England Journal of Medicine how a series of mistakes led him to operate incorrectly on the hand of a 65-year-old woman.
Doctors never admit mistakes because of an irrational fear of liability. Patient safety advocates praised Ring’s seven-page mea culpa as a necessary step to reversing rising numbers of wrong-site surgeries and other errors. “My immediate reaction was ‘Bravo!’” said Dr. Helen Burstin, senior vice president for performance measures at the National Quality Forum, a safety coalition famous for pioneering a list of what were once called “never events,” medical mistakes that should never occur.
Ring, along with colleagues at Massachusetts General and Harvard Medical School, detailed the series of missteps that led to the wrong operation in the patient whose ring finger on her left hand was stiff, painful and sometimes got stuck in a flexed position, a condition known as "trigger finger."
The patient was the last operation on a day that included three major surgeries and three minor surgeries. Stress was high because several other surgeons were behind schedule. Time equals money. As a result, the patient was moved to a different operating room at the last minute, with different staff, including the nurse who had performed the pre-operative assessment.
No “time out” protocal was completed. A time out is the safety pause for the medical staff aimed at double-checking surgical sites, but no formal check occurred. In addition, there was a change in nursing staff in the middle of the procedure and a bank of clinical computers that diverted nurses’ gazes away from the patient.
Ring performed a carpal-tunnel-release operation, instead of a trigger-finger-release procedure.
“About 15 minutes later, while I was in my office dictating the report of the operation, I realized I had performed the wrong procedure,” Ring wrote.
Ring notified the staff, the patient and the hospital’s safety team. Massachusetts General Hospital officials reviewed the error, reemphasized safety protocols and coached Ring and others involved in ways to avoid specific mistakes in the future. Hospital officials offered her a settlement.
In 2008, the most recent year with complete records, 116 wrong-site surgeries, up from 93 in 2007, were recorded by the Joint Commission, a national hospital accrediting agency. Preliminary reports logged 137 wrong-site surgeries from March 2009 through June 2010. That’s despite more than a decade of attention to the issue following the landmark 1999 Institute of Medicine report titled “To Err is Human.”
One in every seven hospitalized Medicare patients are harmed by treatment mistakes, according to new analysis by the Department of Health & Human Services. Researchers estimate that these types of adverse events contribute to 15,000 deaths per month or 180,000 deaths each year.
"Adverse events" or causes for treatment errors, including excessive bleeding after surgery, urinary tract infections linked to catheters and incorrect medications.
"The country is in a patient safety crisis," said David Arkush, the director of Public Citizen’s Congress Watch Division in a statement. "The only workable solution to preventing unnecessary deaths and injuries is to combine much more patient-protective hospital protocols with much better scrutiny by hospitals of physicians and other health care providers, and to appropriately discipline those whose performance results in preventable patient harm."