A Doctor’s Confession Highlights Simple Method to Reduce Surgical Errors

After a particularly boneheaded mistake, the first instinct is to hide the evidence, with the urge to hide proportional to the gravity of the mistake. But after the worst blunder of his career as a surgeon, Dr. David Ring’s reaction was different.

Two years ago, with a patient expecting surgery on one of her fingers, Ring performed an entirely different operation to alleviate carpal tunnel syndrome.

Back in his office after the procedure, Ring realized what he’d done, and immediately went back and informed the patient. After explaining the mistake, he returned to the operating room with her in order to perform the correct operation.

Ring has followed up with an unusual confessonal article in the November 11 edition of the New England Journal of Medicine, in which he outlines the series of events leading up to the erroneous surgery: Ring had had an emotionally draining experience with another patient earlier; the woman who received the wrong procedure had switched rooms with a carpel-tunnel patient; the incision point was not marked; and, crucially, Ring and his team neglected to perform the “timeout”, which amounts to a final check of the incoming patient and the procedures to be carried out, in order to avoid mistakes.

The goal of the article was to help other doctors avoid his misfortune. “I hope that none of you ever have to go through what my patient and I went through,’’ Ring wrote. “I no longer see these [timeout] protocols as a burden. That is the lesson.’’

Fittingly, in the same issue of the New England Journal, a team of Dutch researchers published a study demonstrating the overwhelming value of running through a final checklist to reduce surgical errors. Comparing hospitals that use pre-surgery checklists with those that don’t, the researchers found that surgical complications fell from a level of 27 percent to just 17 percent. Deaths at the hospitals using the checklists dropped from 1.5 to 0.7 percent.

Dr. Atul Gawande, a longtime proponent of the timeout procedure, voiced excitement upon hearing about the study.

“It’s huge,” Gawande told The Boston Globe. “They independently validated the finding that safe surgical checklists can make a massive reduction in complications and deaths. Imagine a pill that could reduce surgical complications and deaths by more than a third. It would be a multibillion-dollar blockbuster.”

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