There has been significant media attention on a New England Journal of Medicine case report where a surgeon, Massachusetts General Hospital’s David Ring, described how he operated on the wrong hand of a patient.
Here’s a summary of the case:
Ring, along with colleagues at Massachusetts General and Harvard Medical School, detailed the series of missteps that led to the wrong operation in the patient whose ring finger on her left hand was stiff, painful and sometimes got stuck in a flexed position, a condition known as “trigger finger.”
The patient, a Caribbean native who spoke only Spanish, was the last operation on a day that included three major surgeries and three minor surgeries, Ring wrote. No interpreter was available, so Ring, who speaks Spanish, was asked to translate for her.
Stress was high because several other surgeons were behind schedule. As a result, the patient was moved to a different operating room at the last minute, with different staff, including the nurse who had performed the pre-operative assessment.
Ring spoke to her in Spanish, which was mistakenly interpreted by a nurse in the room as a “time out,” the safety pause for the medical staff aimed at double-checking surgical sites, but no formal check occurred. In addition, there was a change in nursing staff in the middle of the procedure and a bank of clinical computers that diverted nurses’ gazes away from the patient.
In the world of medical error, where the truth is often clouded in secrecy, taking the bold step of publicly describing your mistake is a brave one. Some would say it’s long overdue.
There have been studies that show an apology and admission of error lead to a lower rate of being sued. Beyond the malpractice implications, it’s simply the right thing to do. So, why isn’t it happening more often?
In 2006, then-Senators Hillary Clinton and Barack Obama penned a perspective piece in the NEJM, noting that many errors in medicine were not due to bad doctors intentionally trying to hurt patients, but on system-wide errors — similar to Dr. Ring’s case:
We all know the statistic from the landmark 1999 Institute of Medicine (IOM) report that as many as 98,000 deaths in the United States each year result from medical errors. But the IOM also found that more than 90 percent of these deaths are the result of failed systems and procedures, not the negligence of physicians. Given this finding, we need to shift our response from placing blame on individual providers or health care organizations to developing systems for improving the quality of our patient-safety practices.
The malpractice system does a lousy job to improve patient safety (along with poorly compensating injured patients). The mere fact that the media is making such a big deal about Dr. Ring’s story is a testament to that. It’s that rare. Every error should be discussed in the open, used to improve the care of our patients, and reduce the risk of future mistakes.
The fact that that’s not happening can be chalked up to the adversarial nature of our flawed malpractice system, which encourages secrecy, suppresses apologies, and does little to improve patient safety.