“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.”
Those are the words of Dr. David Ring, a hand and arm surgeon at Massachusetts General Hospital which were published in this week’s edition of The New England Journal of Medicine.
To his credit, Dr. Ring asked for a discussion of the medical errors that led to the wrong operation on his patient. Rather than performing a trigger-finger release procedure on the patient, Dr. Ring mistakenly performed a carpal-tunnel syndrome correction instead. In his recollection of the day’s events, Ring noted a high level of tension in the surgical wing. Other surgeons were behind schedule. According to the Boston Globe, “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.”
Dr. Ring made public his errors to emphasize the need for following proper checklist procedures and universal protocols, especially in moments of high stress, fatigue, and chaos in the operating room. Medical errors are made when doctors and healthcare workers forego these vital checklists and protocols. Hopefully, Dr. Ring’s colleagues will read this nightmare scenario and change their behaviors and attitudes about the procedures and checklists. They are in place to protect the patient and improve patient safety.
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