Doctor Gives Public Mea Culpa After Surgical Mistake

A Boston-based doctor gave a public mea culpa after the wrong patient surgery

November 11, 2010, 12:30 PM

Nov. 11, 2010— -- 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.

In 2004 the Joint Commission, a non-profit that accredits health care organizations and programs, created the Universal Protocol, a global checklist with safety guidelines including a sign-in, recognition of the surgery site, and a time-out to be done before, during and after an operation. The procedures have proven to lower surgical mistakes significantly and save money.

Dr. Atul Gawande, a general and endocrine surgeon at Brigham and Women's Hospital in Boston and director of the World Health Organization's Global Patient Safety Challenge, helped create the WHO "Safe Surgery Saves Lives" Checklist, which includes procedural safety questions before the patient is given anesthesia, before the first skin incision, and before the patient leaves the operating room. In a study published in the New England Journal of Medicine in January 2009, the safety guidelines proved to reduce complications, surgical errors, and death associated with surgery procedures by more than 30 percent.

Surgical Errors Appear to Be Rising

But in a study published in October in the Archives of Surgery, Denver researchers analyzed 27,370 physician-reported adverse events from the Colorado Physician Insurance Co. database and found that Colorado doctors operated on the wrong body part 107 times and performed surgery on the wrong person 25 different times. Twenty percent of the wrong-patient procedures and 38 percent of wrong-site surgeries caused significant harm to patients. One patient died after the doctor operated on the wrong body part. And the number of occurrences went up from 2002 to 2007.

"I was shocked when I saw the numbers," said Dr. Philip Stahel, lead author of the study and director of orthopedic surgery at the Denver Health Medical Center. "I'm not sure if the number of mistakes went up or the reporting of the mistakes went up. Increased vigilance could meet increased reporting."

Preventative Measures Cannot Stop All Medical Errors

Despite safeguards in hundreds of different hospitals, major mistakes still happen. And doctors say the errors are likely to be underrepresented and underreported.

"Just like aviation, we want plane crashes reduced to zero," said Stahel. "This is like a jumbo jet crashing once a week. There should be zero tolerance to these complications."

For three years, Edie Bickoff watched her longtime boyfriend, Richard Flagg, suffer with a lung tumor. On Sept. 5, 2000, Flagg had been admitted to a New Jersey hospital to have the benign mass removed from his left lung. According to Bickoff, Flagg had hoped to get back to work as an oil barge captain soon after the surgery was over.

That was before the surgeon at the hospital operated on the wrong lung. Bickoff said the doctor removed nearly half of Flagg's healthy right lung. By the time doctors had realized the mistake, she said, Flagg had lost so much of his healthy organ that removing the tumor and surrounding tissue from unhealthy left lung was no longer an option. The tumor burst three years after the botched surgery, and Flagg died at age 63.

"I'm not at peace because I lost the love of my life," said Bickoff, a 61-year-old resident of Milford, Pa. "When you see someone treated the way he was treated with such ghastly consequences, it's just awful."

But while no patient wants to be the one to have the wrong foot amputated or have a sponge left in their body, some physicians said the idea of this zero tolerance is simply impossible.

Dr. David Feldman, chief safety officer and vice chair of surgery at Maimonides Medical Center in Brooklyn, N.Y., is an advocate of safety guidelines and regimented protocols. Before each surgery, every person in his operating room introduces themselves. Doctors reiterate the patient's name and surgical site and quickly go over procedures again.

Before the patient leaves the room, doctors at Maimonides, among other things, wave a detector over the patient's body designed to spot any soft items like sponges or towels if they have been left in the patient after surgery. Pathology labels are double-checked to be sure the correct name is on the labels.

To Err Is Human?

But despite such cautionary practices, Feldman said he did not think surgery will soon be just right. "We as a society have an expectation of perfection, but it's unrealistic to think surgeries will be perfect," said Feldman. "Humans are not perfect beings, and there are always going to be mistakes."

Dr. Thor Sundt, professor of surgery at Mayo Clinic, agreed.

"These errors are unfortunately inevitable because of the complexity of the business we're in," said Sundt, another strong advocate of surgery guidelines. "The trick is error management. Everyone on the team must be mindfully engaged and empowered, so they can capture those errors and correct them."

Charles Perrow, professor emeritus of sociology at Yale University, wrote "Normal Accidents," a book that examines the complex systems that surround us. The more complex the system, Perrow says the more likely there will be errors.

"When you move from one person to two persons you get a 'crack' that something might fall into," Perrow said. "With a half a dozen people in the operating room the number of possible cracks increases exponentially. We always make mistakes and we hope that others will catch them before they do too much damage, but with increased specialization the others are less likely to catch our quite specialized mistake."

Sundt and his colleagues at Mayo Clinic, meanwhile, have taken safety guidelines one step further than the university protocol. Before every surgery, Sundt pauses to confirm the name of the patient, the procedure that is about to take place, antibiotics dosage and any special equipment that is needed in the operating room. In 2010, medical briefings were also made mandatory at Mayo Clinic. While a checklist is the same for every surgery, briefings change for different surgeries. The idea is to make everyone, including the patient, comfortable enough to speak up if necessary. Even when a nurse ends a shift, he or she must brief the new nurse on the specific operation at hand.

"Everyone, including patients, needs to be part of the team and be an active participant in the process," Sundt said.

Patients have been known to use permanent markers to write on their bodies to mark a surgery site. Feldman said patients should ask questions, reiterate the surgery to the doctor, go ahead and write on themselves to help map out their surgery -- and even make sure the surgeon has washed his or her hands.

"Some doctors might get annoyed to have a patient ask if they've washed their hands, but if that's the case maybe that patient shouldn't be seeing that doctor," said Feldman. "Doctors have to realize that encouraging patients to be involved and ask questions all helps with patient safety."