Admitting a mistake and learning from it is common wisdom, but in the medical field, medical providers rarely admit they make mistakes, leading to a climate of distrust and less patient safety. That’s why it’s important to highlight instances where a medical provider admits a mistake and applaud that medical provider for taking a courageous step toward minimizing the chances that similar mistakes are repeated. In a story covered online by MSNBC, one brave doctor recently wrote about his surgical mistake in a recent edition of the New England Journal of Medicine.
Dr. David C. Ring explained that was supposed to conduct a ‘trigger finger’ surgery on a 65-year-old Spanish speaker to relieve a painful condition where a finger can get ‘stuck.’ However, Dr. Ring mistakenly performed a carpal tunnel release. Dr. Ring attributed this surgical error to a series of deviations from established routines: (1) there was no interpreter available, so Dr. Ring, who speaks Spanish, spoke to the patient in her native tongue; (2) surgeries were behind schedule at the hospital; (3) no formal ‘double check’ occurred to ensure the correct procedure would take place; and (4) there was a change of nursing staff in the middle of the procedure. Human errors like the one Dr. Ring and the staff committed are more common when important routines are overlooked or when people are in a rush.
The doctor admitted his mistake to the patient and performed the correct procedure for free. Thankfully, this surgical error did not result in a devastating injury that never should have occurred.
Dr. Ring should be recognized for his bravery. He risked the embarrassment and loss of confidence that comes with admitting a mistake for the sake of recommitting to established protocols and preventing this mistake from ever happening again. A similar story was the focus of our November 2, 2010 blog that highlighted a pilot project for reporting medical errors so that they can be studied and remedied. These are important steps that need to be taken to improve patient safety in our country.