In hindsight, just about everything that happened throughout the course of the day seemed to foretell the surgical error that would come to haunt David C. Ring, MD, and the 65-year-old woman on whom he mistakenly performed a carpal tunnel release instead of the trigger finger release she'd elected.
The woman had elected to undergo corrective surgery to relieve idiopathic trigger finger of her left ring finger at Massachusetts General Hospital's day surgery unit. She was to undergo the procedure with local anesthesia at the end of a long day when her surgeon, Dr. Ring, had 3 larger cases and 2 other hand procedures — both of which were carpal tunnel surgeries. In a detailed account of the incident published in the New England Journal of Medicine, Dr. Ring recalls beginning the day with the mindset, "I have three big procedures that I have specifically planned and prepared for and a few "'carpal tunnels' to perform today."
That erroneous mindset was just the first in a series of events and mistakes that resulted in the trigger finger patient receiving carpal tunnel surgery instead. According to the NEJM report, there were other "active and latent errors" that occurred that day, leading up to the wrong surgery:
Poor scheduling and staffing resulted in operating room delays at the facility, causing a stressful atmosphere and a last-minute room and personnel change on the trigger finger case.
The patient's left arm was marked at the wrist, but not at the surgical site (left ring finger), and the marking was washed away during prepping.
Dr. Ring was called upon to act as interpreter for the trigger finger patient, who spoke only Spanish, in lieu of a professional interpreter who could keep the entire surgical team in the loop.
The final pre-operative time out was skipped, because a nurse in the OR mistakenly believed a conversation in Spanish between the surgeon and patient constituted the time out.
Dr. Ring had been distracted by a previous patient who had become very emotional and required extra attention in the PACU. "I recall privately counseling myself that the next operation would be 'the best carpal tunnel release that I have ever performed,'" says Dr. Ring, referring to the trigger finger release case.
About 15 minutes after completing the carpal tunnel release on the patient, Dr. Ring realized his error while dictating the case, and immediately informed both the staff and the patient of the error. She agreed to have him perform the correct procedure that day, which he did without complication.
Although she allowed him to correct his mistake, the patient ultimately said she lost faith in Dr. Ring and sought subsequent treatment elsewhere. The hospital waived all her charges and reached a financial settlement with her.
Dr. Ring's account of the incident, unique in its candor, was motivated by his desire to prevent similar errors. "I hope that none of you ever have to go through what my patient and I went through," he writes in the NEJM. "I no longer see these protocols as a burden. That is the lesson," he adds, referring to the Joint Commission's Universal Protocol for preventing wrong-site, wrong-procedure and wrong-patient procedures.
Mass General updated and strengthened its Universal Protocol policies in the wake of Dr. Ring's error, and now has an auditor from the Center for Quality and Safety observe performance of the protocol in all inpatient and outpatient procedural areas, according to the report.
Irene Tsikitas
