Archive April 2018 XIX, No. 4

Editor's Page

We All Make Mistakes, But Few Talk About Them

Dan O

Dan O'Connor, Editor-in-Chief


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This issue features back-to-back articles on never events — retained objects and wrong-site surgery. It's refreshing that both are first-person accounts bravely told by a nurse and a surgeon you'd certainly excuse if they passed on the chance to talk about how they messed up.

But in swallowing their foolish pride and mustering the courage to show they're fallible, they rose above medicine's blame-and-shame culture that makes it nearly impossible to admit mistakes — not I made a mistake, but I am a mistake — let alone learn from them and prevent them happening again to another patient and provider.

· In "Almost Left Behind" on p. 18, Jean Campbell, MSN, RN, the assistant manager and clinical educator of surgical services at Alton (Ill.) Memorial Hospital, takes us along on her investigation into how an OR team closed a patient with 2 sponges inside her. Though technically a near miss because the patient was still in the OR when they realized the error, they had to put the patient back under and reopen to get the sponges out.

· In "The Ink Must Go Where the Knife Will Cut" on p. 22, hand and arm surgeon David Ring, MD, PhD, tells for the umpteenth time how he performed the wrong hand surgery procedure. Dr. Ring says he felt "devastating shame" when he realized he had released the carpal tunnel when he was supposed to release a trigger finger.

"When I realized my error, it was like the ground fell away from beneath me," says Dr. Ring. "As if my breath was taken from me."

But Dr. Ring famously wrote about his error in the New England Journal of Medicine. After that article ran, Dr. Ring went on what he calls the "wrong procedure world tour," as he was invited to speak near and far about his story. He entitled the talk: "About My Error" and snapped the audience to attention with his opening line:

"We're going to do something unusual today. We're going to talk about my error."

Alton Memorial didn't run from its near miss. They presented a poster at AORN and worked with us on this month's cover story.

"People are very afraid to show that they're fallible, but we all make mistakes," says Ms. Campbell. "Let's grow from them. It's such a learning opportunity. Rather than let it eat at you, get it out so that others can learn from it. We have to make it better for each patient so it doesn't happen again."

Yes, we all make mistakes. But few of us are in a hurry to admit them.

We hope not, but a few typos or misplaced commas might have snuck into this issue. If you spot one, please let us know so we can own up to it, talk about it and learn from it. OSM

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