In the same issue of the New England Journal of Medicine that contains a research article confirming the value of surgical checklists, a Boston surgeon tells his story of performing the wrong operation on a patient, one misstep at a time.
Dr. David Ring, a hand and arm surgeon at Massachusetts General Hospital, describes what happened in the "Case Records" section of this week's journal, a regular feature in which unusual situations are discussed. This time the problem is a cascade of errors and omissions that led to Ring's performing the wrong operation on his patient's finger. His patient needed relief of a problem with her left ring finger, a procedure called trigger-finger release, but the doctor actually performed a carpal-tunnel syndrome correction instead.
The mistake occurred at the end of a long day, which included an emotional encounter with the previous patient over use of a local anesthetic. The operating room was changed at the last moment, the nurse who had done the pre-operative assessment was not there, the correct arm was marked but not the incision point, and Ring's speaking to the patient in Spanish was mistaken as the "time out" before proceeding, which is a moment when the surgical team stops to be sure they are clear on what needs to be done. No checklist -- a standard series of questions -- was run through.
Ring realized his mistake when he was in his office dictating his report on the operation. He immediately told the staff, informed the patient, and apologized to her. She agreed to have him do the correct procedure right away. She went home that day, but declined to have him care for her afterward, through her son. The hospital waived its fees and paid a financial settlement that was negotiated soon after. For patient confidentiality reasons, the date of the procedure was not disclosed, but the case was presented at a hospital department conference in January 2009.
The consensus of Ring's Case Records colleagues is that systems in place to prevent errors, whether they are called checklists or protocols, work only when they are used
Ring said he went public with his case to help others.
"I hope that none of you ever have to go through what my patient and I went through," he wrote. "I no longer see these protocols as a burden. That is the lesson."
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|White Coat Notes covers the latest from the health care industry, hospitals, doctors offices, labs, insurers, and the corridors of government. Chelsea Conaboy previously covered health care for The Philadelphia Inquirer. Write her at email@example.com. Follow her on Twitter: @cconaboy.|
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