Archive June 2014 XV, No. 6

About My Error

The orthopedic surgeon talks about his wrong procedure in order to share the lessons learned.

David Ring, MD, PhD


hard-stop time out HARD STOP David Ring, MD, PhD, leads a hard-stop time out. "Everyone is helping get things right," he says.

People still ask me to talk about my error. Talking about it respects the patient that was harmed. Talking about it helped me heal. Talking about it helps other patients, other surgeons and their teams embrace a safety culture, adopt checklists and encourage each other to speak up. Let's talk about my error.

My error
A 65-year-old woman came to the day surgery unit at Massachusetts General Hospital in Boston a few years ago for a trigger-finger release, a procedure I'd performed hundreds of times. Due to a confluence of events, I performed a carpal-tunnel release on this patient rather than a trigger-finger release.

About 15 minutes later, while I was in my office preparing to dictate the report, I realized that I had performed the wrong procedure. It's difficult to describe the feeling I had. Others have helped me try to put this into words. It's like the ground fell from beneath me. Like my breath was stolen. It was the typical layers of "Swiss cheese" that let my error cause harm:

  • A backed-up schedule moved my patient to another OR and bumped the nurse who had performed the pre-operative assessment from the case.
  • A time-out policy that did not require the entire team to stop and be involved. What's more, we performed the time out before we'd prepped and draped the patient.
  • A site-marking policy whereby we marked the limb, but not the specific operative site. What's more, the site marking was wiped away by the alcohol in the prep and povidone-iodine.
  • Then there was the language barrier. The circulating nurse thought that I would be doing the time out in Spanish — she was excluded from helping me because she did not speak Spanish.

After informing the patient of the error and apologizing, I offered to perform the correct procedure. She agreed. I reassembled the staff and performed a trigger-finger release, without complication. Other than an unnecessary incision on the palm, there was no lasting harm for my patient.

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