Thursday, November 11, 2010

Bravo, Dr. Ring!

Health Care on reports about a recent article in the New England Journal of Medicine about a surgeon's operating room error in Boston. What makes the article unusual is that it was written by the doctor who made the mistake.

Dr. David Ring from MGH presents a clear and understandable summary of the case, what went wrong, how he handled the disclosure to the patient, and many other important details.

He says, “Just imagine the worst thing that’s ever happened to you and that’s how it feels. I don't want anybody to make the same mistake I made."

In writing this article, Dr. Ring follows in the footsteps of Dr. Ernest Amory Codman, an MGH doctor from decades ago: "Dr. Codman made public the end results of his own hospital in a privately published book, A Study in Hospital Efficiency. Of the 337 patients discharged between 1911 and 1916, Dr. Codman recorded and published 123 errors."

Congratulations to Dr. Ring and to MGH for taking this step. As we have found in our own case, wide disclosure of such errors is the best way to learn from them and help avoid them in the future. It also sends a clear message to other clinicians that reporting of errors will be handled in a just manner.

Addendum to my original post (now edited), with still more thanks to Dr. Ring:

As another interesting twist to this, the first web article about this was a case of "wrong-site journalism" which unfortunately I got caught up in as well. The first article implied that this was a wrong side surgery. But it was the wrong surgery on the correct side, not wrong side surgery. The piece has a disclosure of the error on the top of the page now. Oddly enough, I wrote my original post with the wrong interpretation -- even though I read the NEJM article. Apparently I got trapped by my own bit of cognitive anchoring by reading the earlier article! As Dr. Ring says in a note to me: "To err is clearly human, which only helps emphasize the points that we all believe are so important to make."


DBerry said...

" “Just imagine the worst thing that’s ever happened to you and that’s how it feels..."

Sounds like something BP's Tony Hayward would say.

Paul Levy said...

Oh, come on now. If you read the article, you can see that he was truly upset for what the patient had experienced.

The comment you quote, in my mind, is meant mainly for other doctors, to make them alert to the seriousness of this kind of error and to encourage them to follow proper pre-surgical and other protocols.

And remember the context, too. He has published, for the world to see, details of his own errors so others will avoid them. That is not the sign of an unsympathetic person. If he just cared about himself, he could have gone on and never written the article.

Anonymous said...

To me the most cogent comment Dr. Ring made was;

"I no longer see these protocols as a burden. That is the lesson."

That is the lesson for everyone involved in an OR, indeed.

As for DBBerry, unless you've been there, you don't get it. He's serious.

nonlocal MD

Stephen said...

From Facebook:

The NEJM article makes fascinating reading, and I too commend the surgeon and the hospital for their forthrightness.

Bob said...

From Facebook:

This is a remarkable article...

Marilyn said...

“Just imagine the worst thing that’s ever happened to you and that’s how it feels."

That's how a professional medical care provider feels when they make a mistake.

Thank you, Dr. Ring for admitting it.

Jeffrey N. Catalano said...

This case demonstrates that certain people like Dr. Ring simply get it. We all know about the University of Michigan Health Care System, which is highly touted for its program that discloses medical errors and
offers early compensation to patients, which significantly decreased lawsuits. Rick Boothman, the Michigan in-house attorney, believes that it is important to be up front with patients when medical errors happen, and pay quickly when a case warrants it, rather than dragging everybody
into court. Mr. Boothman was quoted in a recent Newsweek article
entitled "Do No Harm." as saying "Its the decent thing to do . . . The sky doesn't fall when you are open and honest." Nevertheless, as the article goes on to state, a culture of ignorance, arrogance, and
intimidation rule the day. Errors typically are not reported, physicians are not questioned, and some health care providers who have reported mistakes have been persecuted. Dr. Ring's case could have ended up in expensive and
protracted litigation which would have put the patient and physician
through hell.

It is encouraging that Dr. Ring and Mr. Boothman understand that
sometimes the decent thing to do is also the right thing to do.
Hopefully, others will follow their lead, especially when the stakes are higher and involve permanently disabled or dead patients, and the mistake is not so transparent to the patient.

Anonymous said...

As a patient that has had to deal with a medial error,and adverse outcome, this is what the patient wants most...Learning.
Awesome job Dr. Ring. It took a lot of inner awareness and compassion to write this article.

lynnie said...

mistakes can't be fixed if those of us who make them(which is everyone) are caught up in an environment that doesn't see fit to support the fact that, we are human.
If clinicians are encouraged to: A)realize their not infallible
B)analyze, as part of a team, what went wrong, include the patient/family
C)Make corrections based off of this analysis, so they and others can learn from this.
Well, then that clinician would have probably prevented tons of other patients from going through unfortunate experience of a preventable error! Way to go MGH, Dr Ring!

DBerry said...


What makes you think that Tony Hayward didn't feel the same was Dr. Ring? That was my point.

Protocols were established to preclude Dr. Ring's error... yet he gets your props while Tony Hayward was operating 'without a net' yet is villified.

You all give Ring too much credit for writing about his disturbing failure to follow established protocol. Glad he wasn't scheduled to amputed one of his patient's legs.

Anonymous said...

Dear DBerry;

I am afraid you missed the point of the entire case presentation, which was that the surgeon alone is no longer considered solely responsible for such an error. If you read p. 1955 of the article (which is not subscription-only, so you should have no trouble accessing it), you will learn about the Swiss cheese model of harm and about the many active and latent errors which led to this outcome.

That is the entire lesson; that human error is inevitable and systems must be designed in such a way to prevent it.Please read the article.

nonlocal MD

Anonymous said...

I proudly point out that the "new" protocols the MGH says in the NEJM article they will implement to avoid recurrence of this error are the protocols we have been using for years in our OR at BIDMC.

I have somewhat mixed feelings about the article, though. I admire the open admission of the error, but there is an awful lot of "the nurses switched" "my room was switched" "there was a delay" and not enough of "yes, but she was MY patient who was spoken to by ME before the surgery and even with all the changes in room and nurses it was ME who made the mistake."

Sometimes "everyone's responsibility" becomes "no one's responsibility" (this is why every summer we hear of children drowning at family gatherings because everyone thinks "someone else" is watching them.) In this case, without the protocols we follow here (and they now follow there) this is really an individual error---with a systems solution put in place as a result.

I am also interested by the "settlement with the patient" mentioned in the article. Yes a "never" mistake was made, but was this patient really harmed by the "extra" inadvertent carpal tunnel release under local anesthesia? On the same hand she was recovering from the trigger finger release anyway? I would think not, and wonder how many health care dollars went to this instead of to health care. (Let's not kid ourselves that these payments do not drive up the cost of health care for everyone.)

Anonymous said...

I commend the surgeon for exposing his error. However, while reading the article I wondered why he did not publish the case in a surgical journal that is read by his colleagues instead of the New England Journal of Medicine, if his intention was to promote the importance of adhering to safety protocols. Not that many surgeons have a subscription to the NEJM. And it is unclear how our medical colleagues benefit from this case report. The knowledge that surgeons make mistakes is well known by the medical community and Dr. Ring did not exactly provide new insights in its cause or prevention.

Allow me to be skeptical: could it be that it was the surgeon's unrestrained ambition, rather than his noble desire to educate his fellow surgeons, that was the driving force behind publishing this ‘mea culpa’ (but mostly the nurses’ culpa)? Of all journals, he decided to publish the case in the New England Journal of Medicine – the journal with one of the highest impact factors in the medical literature.

Openness is critical in medical care. But what does a surgeon gain from reading this case report? That you should be careful with your procedures, otherwise you will feel horrible? What does a patient gain from this particular case? That they should feel secure now because after this incident MGH has implemented safe-surgery protocols? That some surgeons are honest when they make a mistake on your body? As it stands, the only thing that has happened as a result of this publication is damage to his reputation and that of the department (simply Google David Ring surgery).

Paul Levy said...

Well, your comment certainly has me confused.

Dimi said...

"In a 2003 survey of hand surgeons, 21% of the surgeons reported having operated on the wrong site at least once in their career, and 2% more than once"

Honestly, 21% is more than 1/5 of all hand surgeons! And if we assume that there was a number of surgeons without dignity (Dr. Ring fortunately is not one of those), we could easily assume that this percentage is much higher. Obviously, either the surgeons are generally incompetent, or the system is totally failing, or both.

People do mistakes, but mistakes lead to consequences. Money cannot buy destroyed health, either excuses or regrets. Disciplinary actions are needed, because people should in one or in another way "pay" for their professional errors. If I was the patient, this is what I would have wanted - to see all involved individuals kept responsible in some disciplinary way for their mistakes. This may or may not include even the CEO of the hospital. Was that done? What were the personal/professional consequences for the involved personnel?

When money becomes a necessity rather than a goal for the hospitals and their doctors, then we could move on to an almost error-free practices.