Dr. David Ring, a surgeon at Massachusetts General Hospital, had wrapped up his final operation of the day and returned to his office dictate his report. But as he began to record, the enormity of what he had done hit him cold.
"I realized I had performed the wrong procedure," he wrote in the New England Journal of Medicine. "I hope that none of you ever have to go through what my patient and I went through."
It was a mea culpa that most doctors would never dream of making public. Ring described a flurry of missteps which led to a wrong-site, wrong-procedure he performed about two years ago.
For his last operation that day, Ring would see a 65-year-old patient who was admitted to surgery for trigger finger in her left ring finger. The condition describes a finger or thumb that catches in a bent position and then straightens with a snap, much like a trigger.
Ring went through the all the necessary steps -- he verified the symptoms, the abnormal findings on her physical examination and the informed consent. He confirmed the trigger finger was on the patient's left ringer finger and reviewed the procedure with her.
But then Ring left to perform a carpal tunnel release on another patient.
When he returned, he noticed a switch in the operating staff. Stress ran high among surgeons since several surgeons were behind schedule, he wrote. Ring's mind was wrapped around the previous carpel tunnel procedure he just performed. The patient's arm had been washed with soap, alcohol, and povidone-iodine. The alcohol had caused the surgery site-marking to wash off. And when Ring spoke to his patient in Spanish moments before the procedure, the circulating nurse didn't understand.
And so describes the snowball that contributed to Ring's realization. He performed a carpal-tunnel release, removing a band of tissue around the wrist -- a common procedure to treat carpal tunnel syndrome. He should have performed a trigger-finger release, which required cutting a tendon in the finger.
Ring rushed back to the patient, told her the mistake, and performed the necessary procedure.
While Ring described the encounter as one of the largest operating mistakes in his career, these -- at times fatal -- errors are not so uncommon. In fact, 21 percent of hand surgeons said they operated on the wrong site at least once in their career, according to a 2003 survey by the American Academy of Orthopedic Surgeons.
Between 44,000 and 98,000 Americans die each year in U.S. hospitals from preventable medical errors, and hospital errors rank between the fifth and eighth leading cause of death, according to the Institute of Medicine. Some 68 percent of error claims are related to orthopedic surgery.
The formal, and very public, apology comes on the heels of a study published Wednesday in the New England Journal of Medicine that found comprehensive surgical checklists helped to reduce mortality rates and surgical mistakes in hospitals.
In the new study, Netherlands researchers assessed the impact that a comprehensive checklist had on surgical safety in six hospitals. The authors compared the surgical outcomes in almost 4,000 patients and found that surgical complications were reduced to 10.6 percent from 15.4 percent after the checklists were implemented.