Sharing a Surgical Mistake with the World

November 11, 2010

To err is human. To share it with the world is not, except in the case of surgeon David C. Ring.

To err is human. To share it with the world is not, except in the case of surgeon David C. Ring.

The latest edition of the New England Journal of Medicine includes details of an incorrect surgery performed by Ring on a patient at Massachusetts General Hospital. The woman, 65, came to the hospital to receive release "trigger finger" - or a locking up - of her left ring finger. She got carpel-tunnel release surgery instead, according to Ring's reporting of the incident.

Ring, a hand and arm surgeon, details a number of factors contributing to his mistake that day, from stress on the surgical unit due to being behind schedule to lack of a marking on the incision site as dictated by hospital protocol.

The details of the case - and what amounts to a "perfect storm" leading up to the surgical error - should be required reading as they occur every day in practices in hospitals nationwide, so I will not go into detail here so you read it instead. But what I will discuss is how Ring responded afterwards.

In the article, Ring notes that while dictating details of the operation in his office 15 minutes after completion, he realized the mistake. He "immediately" informed staff and the patient, the report notes. Subsequently, he apologized in person to the patient and performed the correct surgery on the woman, with her permission.

The woman elected not to see Ring for follow-up care as her son told the surgeon "she lost faith in me and would not return." He advised a clinic on her postoperative care and the family was not charged by the hospital for her surgery(ies). A financial settlement was later negotiated, Ring reports.

As for why Ring chose to present the case at a departmental conference and have it subsequently published for a national (and thanks to the Internet, international) audience is simple, he said:

"I hope that none of you ever have to go through what my patient and I went through. I no longer see these protocols as a burden. That is the lesson."

Ah, the protocols. The things many see as slowing us down or unnecessary extra work on a daily basis.

Ring shows us, by sharing his own mistake, that protocols are in place for a reason - they help prevent a mistake that affects both staff and patient.

Ring's disclosure has been seen as "exceptionally brave," by some and I would agree. None of us like to make mistakes, let alone have to tell everyone about them. The way Ring details the events leading up to the surgery is wonderful in the worst way. He and his department are having a bad day and he vows to make it up to himself, at least, by "privately counseling myself that the next operation would be 'the best carpal tunnel release that I have ever performed.'"

It may well have been, but it was the wrong surgery for that particular patient.

Ring's story should be printed out and posted on your practice staff bulletin board or e-mailed to your entire office or hospital. It is a reminder that mistakes happen. Yes, we are all human.

But sometimes, we need to share our mistakes with others in order to prevent history from repeating itself. I have no doubt that Ring's disclosure will avoid at least one mistake and perhaps save one life thanks to someone re-thinking their own office protocols.

That is not only human, it is superhuman, that Ring's mistake becomes someone else's moment of clarity.