At the end of a long day, Dr David Ring, a hand surgeon at Massachusetts General Hospital, walked into the operating room and performed the last operation - he did a carpal-tunnel release on his trigger finger patient!
In an extraordinary open admssion of performing wrong surgery in this week's NEJM, Dr Ring said leading up to the wrong surgery were a series of events and mistakes that occurred during the course of the day, such as poor scheduling and staffing, the patient's left arm was marked at the wrist, not at the finger, and the marking was washed away etc.
Dr. Ring realized his error while dictating the report, and immediately notified both the hospital and the patient of the error. He performed the correct procedure that day without complication. However, the patient lost faith in him and sought treatment elsewhere. The hospital waived all her charges and paid a financial settlement shortly after the event.
Dr. Ring asked the case be presented at the departmental conference and published in the Case Records of the Massachusetts General Hospital because he wanted to encourage others to follow procedures that would prevent similar errors in the future. He said "I hope that none of you ever have to go through what my patient and I went through. I no longer see these protocols as a burden. That is the lesson." Dr Ring was praised for his courage by patient safety advocates and his counterparts.
In the same issue of the NEJM, a team of Dutch researchers published a study showing the dramatic effect of implementing surgical safety checklists in reducing surgical errors. Comparing hospitals that use pre-surgery checklists with those that do not, the researchers found that surgical complications fell dramatically from a level of 27% to just 17%. In- hospital mortality decreased from 1.5 to 0.8%, but the outcomes in the 5 control hospitals did not change.
In an accompanying editorial, the author said studies have shown the use of surgical checklists can have dramatic effect in reducing both complications and mortality and believed that they have "crossed the threshold from good idea to standard of care".
Studies have found that serious errors such as wrong-site surgery or wrong patient did occur, often due to simple mistakes or surgical team failing to perform pre-operation checks. Wrong-site surgery occurs in all surgical specialties, 68% of claims in the US related to orthopedic surgery. The American Academy of Orthopaedic Surgeons (AAOS) developed the "Sign Your Site" initiative in 1998 advising surgeons to mark the surgical site with their initials in order to avoid errors.
In the UK, more than 129,000 surgical incidents were reported to the National Patient Safety Agency (NPSA) in 2007. Over 1,000 resulted in severe harm and 271 death. The NPSA issued a patient safety alert in January 2009, requiring NHS organisations to implement the WHO Surgical Safety Checklist for every patient undergoing a surgical procedure. All hospitals in England and Wales must implement use of the Surgical Checklist by February 2010.
The checklist focuses on basic good practice before anaesthesia is administered, before a patient is cut open, and before a patient is removed from the operating theatre, and is designed to promote effective teamwork and prevent infection and unnecessary blood loss. NHS organisations can adapt it for their own use.
Source:
"Case 34-2010 — A 65-Year-Old Woman with an Incorrect Operation on the Left Hand". NEJM 2010; vol 11, 363:1950-1957 ( full text via Athens )
"Effect of a Comprehensive Surgical Safety System on Patient Outcomes". NEJM 2010; vol 11, 363:1928-1937 ( Netherlands trial, full text via Athens)
Editorial : "Strategies for Improving Surgical Quality — Checklists and Beyond". NEJM 2010; vol 11, 363:1963-1965 ( full text via Athens)
1 comment:
Good article. Thank you.
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