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AAOS Now

Published 6/1/2011
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David Ring, MD, PhD

About my error

No matter what happens, take accountability for your actions

It feels like the ground has fallen from underneath your feet and your breath has been stolen—you’ve made a medical error. Is there any way to undo it? Turn back the clock, make amends, make it right? Did it really happen?

In my case, it did—I released a carpal tunnel instead of a trigger finger.

I’m not supposed to make a mistake. My CV is more than 60 pages long, filled with committee service, teaching positions, editorial boards, scientific articles, book chapters, and presentations. Patients, residents, fellows, and colleagues look to me for expertise on how to stay out of trouble. I have been the chairman of the hospital’s Orthopaedic Quality and Safety Committee for a decade.

And yet, I’m human.

I’m fond of asking, “Why did humans invent science?”And the answer is that because the very strengths of human intelligence—pattern formation, rationalization—are what magicians use to fool us. Magicians prefer a smart audience—the smarter the better. The more skilled we are at making sense of something, the easier it is for experts of sleight-of-hand to fool us.

We humans tend to prove our own theories correct. We see the hits and ignore the misses, piling on the support for our instincts and intuition. Heuristics (mental short cuts) are our strength, and because they tend to follow probabilities, they usually serve us well. But when low probability events occur, heuristics can let us down. We humans are very good at fooling ourselves.

We realized this and invented science. The scientist acknowledges that the very strengths of human intelligence are also its weaknesses. The scientist also relies on reproducible experimentation (on objective measurements, blinding, randomization, and independent assessment among other things). This ensures that they are not fooling themselves or being fooled by others.

Does making this error make me a bad doctor? Does it mean that I am reckless, careless, or thoughtless? Was I rushed or tired or overworked? Should I be punished? Can my patients and my colleagues trust me? Can I trust myself?

Or did I fail because I’m human? Did the short cuts that I usually rely on let me down this time? Do I need systems—like I need science—to keep out of trouble?

Aligning the error opportunities
Any number of things might have contributed to my making a mistake that day. Communicating with the patient was one issue. I was the only one who spoke Spanish, and the patient was reserved and could not communicate with the rest of the team. Team changes were made before and during the case, putting the unit under a great deal of stress. The circulator was distracted by the last-minute rush for a tourniquet and worried about getting behind on the lengthy paperwork.

Perhaps most importantly, I was in a carpal tunnel mindset—the small, local anesthesia cases at the end of the day are usually carpal tunnel repairs. I was also very worked-up about a bad experience that a prior patient had with the local anesthesia and determined to “make the next carpal tunnel release my best ever.”

So the error wasn’t due to handling too many cases or being overworked. Instead, I was distracted; I was thinking about the previous anxious patient rather than thinking about the patient on the operating table. My mind was set on doing a great carpal tunnel release.

We also skipped the time out, and the only mark required was on the correct limb rather than at the actual site; and besides, the alcohol in the skin prep removed most of the mark. And so I released the carpal tunnel when I should have released the trigger finger.

I realized it about 15 minutes later, back in my office preparing to dictate. And the ground fell. What do I do now—how do I make it right? I know I can’t undo it, but I’ll do what I can.

Being accountable
I immediately notified the operating room and we prepared to return to do the correct procedure. I then went directly to the patient and apologized. She was sitting, her hand supported on a pillow. I knelt beside her and, as I apologized, my head dropped to the edge of the pillow, tearful. She agreed to return for the correct procedure. During preparations, I called the hospital risk manager and filed a safety report.

Over the next few days I spoke with the patient’s son several times to inform, apologize, support, waive fees, and plan further care when it became clear—understandably—that she had lost faith in me.

And how was I handled? Brilliantly. Within minutes of completing the second procedure, operating room leadership was there to console and support me. The next day when we debriefed as a team, I tearfully apologized. “I blew it,” I said. And our vice president of quality and safety at the hospital responded,“We all blew it.”

Accountability involves acknowledging error and working hard to make sure that no patient and no surgeon goes through what my patient and I experienced. I was accountable for doing the wrong procedure; the hospital quality and safety team were accountable for all of the systems that could have saved me from my error—the systems that we built to help us perform better in spite of our imperfections. I learned that we are in this together.

I also re-learned the following lessons:

  • Sign your site.
  • Operate through your initials.
  • Use the WHO surgery checklists.

I have always been an advocate for quality and safety, but never more so than after making my own error. I vowed to become a more prominent and vocal advocate who would hopefully make a difference.

Making that surgical error was the worst event of my life, but I’m grateful that everyone knew I’d be accountable for my actions.

David Ring, MD, PhD, is associate professor of orthopaedic surgery at Harvard Medical School, chair of the Orthopaedic Quality and Safety Committee, and director of research for the orthopaedic hand and upper extremity service at Massachusetts General Hospital in Boston. He can be reached at dring@partners.org