It is very rare to see a surgeon openly admit to any sort of surgical error. However, one Massachusetts surgeon not only openly admitted to a surgical error, but wrote an article about the incident for the New England Journal of Medicine. His motivation? To alert other practicing physicians of the danger of both "active and latent errors" and to highlight the value of enhanced surgical protocols.

Dr. David C. Ring, a hand surgeon at Massachusetts General Hospital, describes in his article how he accidently performed carpal tunnel surgery on a patient instead of the trigger finger release she had specifically requested.

According to Dr. Ring, there were a number of issues - several of which were created by him - that contributed to the wrong-site surgery.

  • Staffing and scheduling issues created delays in the availability of operating rooms at Massachusetts General Hospital. Consequently, the procedure room and personnel for the procedure both changed suddenly.
  • The patient's left wrist had been marked but not the finger on which the trigger release surgery was to be performed. In addition, the mark on the wrist was washed away during surgical preparation.
  • The patient only spoke Spanish, so Dr. Ring was forced to act as an interpreter. This could have led to the surgical team being misinformed or not receiving all vital information.
  • The final pre-surgery time-out was skipped
  • Dr. Ring had been distracted by a difficult patient earlier in the day

Fortunately, Dr. Ring discovered his medical mistake while drafting post-operation orders and immediately fixed the issue after informing both the staff and patient.

While the hospital instituted the necessary corrective measures and reached a settlement with the patient, she elected not to continue seeing Dr. Ring for treatment.

"I hope that none of you ever have to go through what my patient and I went through," wrote Dr. Ring. "I no longer see [the Joint Commission's pre-surgery] protocols as a burden. That is the lesson."

If you lost a loved one or were seriously injured by a surgical error involving the wrong side, wrong site, wrong patient or wrong procedure, you should strongly consider contacting an experienced legal professional.

This post was for informational purposes only and is not to be construed as legal or medical advice.

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Surgeons Account of Botched Surgery Offers Lessons for Avoiding Errors (Outpatient Surgery)