tag:blogger.com,1999:blog-32053362.post7624341712922157285..comments2024-03-26T00:25:34.026-04:00Comments on Not Running a Hospital: Bravo, Dr. Ring!Paul Levyhttp://www.blogger.com/profile/17065446378970179507noreply@blogger.comBlogger15125tag:blogger.com,1999:blog-32053362.post-83677610256168765622010-11-23T22:36:25.847-05:002010-11-23T22:36:25.847-05:00"In a 2003 survey of hand surgeons, 21% of th..."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"<br /><br />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. <br /><br />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?<br /><br />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.Diminoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-37298068574723260532010-11-16T12:57:50.550-05:002010-11-16T12:57:50.550-05:00Well, your comment certainly has me confused.Well, your comment certainly has me confused.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-4395128608261480762010-11-16T12:33:39.808-05:002010-11-16T12:33:39.808-05:00I commend the surgeon for exposing his error. Howe...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.<br /> <br />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.<br /> <br />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).Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-14416694797315651772010-11-14T20:32:45.360-05:002010-11-14T20:32:45.360-05:00I proudly point out that the "new" proto...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. <br /><br />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."<br /><br />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. <br /><br />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.)Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-10641701674770306792010-11-13T17:01:01.594-05:002010-11-13T17:01:01.594-05:00Dear DBerry;
I am afraid you missed the point of ...Dear DBerry;<br /><br />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.<br /><br />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.<br /><br />nonlocal MDAnonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-14096323927958294542010-11-13T12:25:43.964-05:002010-11-13T12:25:43.964-05:00@all
What makes you think that Tony Hayward didn&...@all<br /><br />What makes you think that Tony Hayward didn't feel the same was Dr. Ring? That was my point.<br /><br />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. <br /><br />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.DBerrynoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-30391403485172188392010-11-12T11:38:52.326-05:002010-11-12T11:38:52.326-05:00mistakes can't be fixed if those of us who mak...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. <br />If clinicians are encouraged to: A)realize their not infallible <br />B)analyze, as part of a team, what went wrong, include the patient/family<br />C)Make corrections based off of this analysis, so they and others can learn from this.<br />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!lynniehttps://www.blogger.com/profile/00788114935838983255noreply@blogger.comtag:blogger.com,1999:blog-32053362.post-20166797365966426582010-11-12T09:09:39.000-05:002010-11-12T09:09:39.000-05:00As a patient that has had to deal with a medial er...As a patient that has had to deal with a medial error,and adverse outcome, this is what the patient wants most...Learning. <br />Awesome job Dr. Ring. It took a lot of inner awareness and compassion to write this article.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-23316542282257273272010-11-12T08:58:18.538-05:002010-11-12T08:58:18.538-05:00This case demonstrates that certain people like Dr...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<br />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<br />into court. Mr. Boothman was quoted in a recent Newsweek article<br />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<br />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<br />protracted litigation which would have put the patient and physician<br />through hell.<br /><br />It is encouraging that Dr. Ring and Mr. Boothman understand that<br />sometimes the decent thing to do is also the right thing to do.<br />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.Jeffrey N. Catalanohttp://victimrights.wordpress.comnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-75641473582985379912010-11-12T07:55:22.996-05:002010-11-12T07:55:22.996-05:00“Just imagine the worst thing that’s ever happened...“Just imagine the worst thing that’s ever happened to you and that’s how it feels."<br /><br />That's how a professional medical care provider feels when they make a mistake. <br /><br />Thank you, Dr. Ring for admitting it.Marilynhttps://www.blogger.com/profile/09719735197987181280noreply@blogger.comtag:blogger.com,1999:blog-32053362.post-88909453602669324022010-11-12T06:50:46.930-05:002010-11-12T06:50:46.930-05:00From Facebook:
This is a remarkable article...From Facebook:<br /><br />This is a remarkable article...Bobnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-38078063196766215682010-11-12T06:50:18.464-05:002010-11-12T06:50:18.464-05:00From Facebook:
The NEJM article makes fascinating...From Facebook:<br /><br />The NEJM article makes fascinating reading, and I too commend the surgeon and the hospital for their forthrightness.Stephennoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-6685555008360852212010-11-12T04:08:36.136-05:002010-11-12T04:08:36.136-05:00To me the most cogent comment Dr. Ring made was;
...To me the most cogent comment Dr. Ring made was;<br /><br />"I no longer see these protocols as a burden. That is the lesson."<br /><br />That is the lesson for everyone involved in an OR, indeed.<br /><br />As for DBBerry, unless you've been there, you don't get it. He's serious.<br /><br />nonlocal MDAnonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-22170773945386413332010-11-11T22:56:45.012-05:002010-11-11T22:56:45.012-05:00Oh, come on now. If you read the article, you can...Oh, come on now. If you read the article, you can see that he was truly upset for what the patient had experienced.<br /><br />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.<br /><br />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.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-87251669756941991342010-11-11T22:51:08.947-05:002010-11-11T22:51:08.947-05:00" “Just imagine the worst thing that’s ever h..." “Just imagine the worst thing that’s ever happened to you and that’s how it feels..."<br /><br />Sounds like something BP's Tony Hayward would say.DBerrynoreply@blogger.com