True - It's great to read that a doctor has realized his own infallibility. I applaude his humility and respect his truthfulness!

It's VERY rare for medical professionals to admit error, even rarer to admit them publically. The US medical profession is a "good 'ole boys club" just like government. Don't tell on me and I won't tell on you.

I don't have a serious error to report on, but I have had a nurse give me the wrong vaccine even though I mentioned the correct one to her as I walked into the clinic. She played the mistake off as if it were my fault. I warned everyone else at my school to watch out for her and to double and triple check before they got poked with anything.

OhMy, Do you think the rarity to admit error might be due to a potential $20 million dollar lawsuit?

Wait ! Elderly ? ? ? at 65 ! ! ! I have never used this term but ROFLMAO! As a 61 year old I take offense. . .

Re; the 20 million dollar settlements, sure. There is also an incredible amount of arrogance and "anointed ones" mentality in the medical field, especially surgery.

People have no idea how difficult it is to admit mistakes at ANY level. Especially in this situation, in today's IT world, for Dr. Ring to reveal it all takes incredible courage. Who has ever revealed all the mistakes, even the "gray" mistakes? There is no one who has not made a mistake and kept it a secret; no matter how small. Look at the economy and the home-loan mess we are in. Everybody was greedy. People knew it was wrong, but nobody ever steps forward and admit their mistake and money greed. I wish we have more Dr. Rings in every profession who has the courage to set things right.

JM, I'm not sure what you're implying. Are you saying that if something you have done warrants a lawsuit that it's ok to lie about it or sweep it under the rug? That kind of goes against medical ethics about doing no harm. It's also why doctors pay a lot for malpractice insurance. It's a high risk profession but they choose to be in it.

I don't know when this happened, but my daughter had very serious surgery on her jaw this past February at Mass General. I can assure you that the team came in and they marked the bejeebers out of the side of her face that had the tumor. We had the surgeon, the surgury intern, the surgery nurse, the anesthesiologist, and the nurse anethetist all come in and talk with us before her surgery. So, things must have changed at Mass General since this incidents and perhaps because of this incident.

I also recommend that you never leave someone in a hospital alone. I'm either the nurse's worse nightmare or their dream. I do all the personal care my family needs while hospitalized, but I question every little thing they do.

As a nurse I would put you in the group of of "my favorite parents"

Good thing she wasn't having an amputation. She'd be learning how to hold a fork with her feet.

This Dr. Ring is a good guy. I respect his honesty and integrity, and would have more confidence in going to him for medical care than many "respected" doctors out there. Medical errors happen but all too frequently, there is a code of silence, co-ordinated deceit and cover-up, and willful attempt to discredit the victim. When this approach is used, the victim suffers much more than just the ramifications of the medical mistake. The effects can be damaging in many, many ways that are never even acknowledged or recognized. Betrayal of trust is very hard to overcome...and when doctors seek to discredit a patient who is a victim of medical mistake, they can influence family members and others who are a part of the victim's support system to come to believe the victim is lying, crazy, a hypochondriac, or worse. I speak from experience...it is a very damaging and unconscionable way to handle medical mistakes, but all too familiar for many victims.

I hope others will take a valuable moral lesson from Dr. Ring. All is well with his soul. Even in medicine, to err is human but to lie about it is purposeful betrayal of the patient and the Hippocratic oath of DO NO HARM. I am not sure how some medical care givers live with themselves...there is nothing greater than a clear conscience and telling the truth.

Glad he wrote about it, but all he did was blame other people.

I KNEW he would blame the nurses

different staff, including the nurse who had performed the pre-operative assessment

Ring spoke to her in Spanish, which was mistakenly interpreted by a nurse in the room as a “time out,”

there was a change in nursing staff in the middle of the procedure

bank of clinical computers that diverted nurses’ gazes away from the patient.

Also it says "No interpreter was available, so Ring, who speaks Spanish, was asked to translate for her"

If he speaks Spanish why would a interpreter be needed?

I would love to hear the nurses perception of what happened

Admitting the mistake negates the potential for punitive damages. To get punitive you must 1. prove your case 2. prove that without the extra award the defendant would do it again. Both instances of "prove" is by a preponderance of the evidence. Doctors get hit by this a lot, because they never want to admit they made a mistake. In fact, the hospital attorney will usually "stonewall" the plaintiff which doesn't help. Medical malpractice damages would fall substantially if doctors would just admit the mistake and apologize. They'll still be hit for compensatory but that depends on how bad they screwed up. The last study done on these instances is that more than 70% of plaintiffs would have settle for just compensation and fixing the issue, but doctors won't admit the mistake. They then go to trial and say, "I didn't make a mistake" and "yes, I would do it again." That's a textbook basis for punitive damages. Just say, "No, I wouldn't do it again" and punitive damages are out, but then you have to explain why you wouldn't do it again if you made no mistake.

jfzs...

I think he is just trying to tell the truth of all the factors he sees that may have contributed to HIS mistake, that he acknowledges. He states that he is hoping his story may bring some positive in helping to prevent future similar mistakes, and so to accomplish that, he wants to explain ALL the possible contributing factors where the mistake COULD HAVE been caught and prevented, but instead became a part of the chain of events that led up to the error.

ohmy9999: The point I was making is that medical malpractice suits can offer outrageously high rewards. This old boys club you describe is not reality as doctors often testify against other doctors who are accused of malpractice. The cover-up is a result of fears about not being able to afford insurance, or having to pay out of pocket because the reward exceeds the insurance limits. The high cost of malpractice insurance is a problem for consumers if we all want affordable health care premiums. Unfortunately, medical errors are not rare, either are deaths caused by errors. The studies I have read suggest that most errors are not gross negligence, but simply a fact of being treated by humans that are fallible. According to a study done by Healthgrades in 2000, 2001 and 2003, found that 195,000 people in the US died from "preventable, in hospital medical errors" http://www.medicalnewstoday.com/articles/11856.php.

None of us expect to be a victim of a medical error. If a doctor does commit a gross error, a lawsuit is valid, but awards should be balanced. Unfortunately, we do pay, indirectly, for outrageous legal settlements and high malpractice insurance costs that are passed along to us with higher premiums.

my ex is a surgeon, i would say that Dr. Ring deserves a medal for coming "out". it's unusual that the story ever gets out of the OR. bravo!!

JM California...

Do not forget that victims of malpractice are not the only ones who are represented by attorneys. Medical Centers have their high powered attorneys on site and doing cover-up and damage control before the patient victim of malpractice even wakes up in recovery. As PatA's above comment says, "it's unusual that the story ever gets out of the OR". Truthfully, any lawsuit that actually has enough substantiated evidence to make it to litigation most often has merit...and deserves compensation. I wish more hospitals and doctors would use all the many thousands or millions of dollars they spend on these high powered, deceptive defense attorneys fighting legitimate claims to instead just admit error, treat these victims with respect and compassion, and compensate medical malpractice victims fairly. It might put a few attorneys on both sides out of a job, but everyone else would be winners in a more honest practice and policy.

Do you seriously think insurance companys are going to substantially lower malpractice insurance premiums or your individual medical insurance premiums if some reduced payout cap on medical malpractice cases or tort reform is enacted? Think again. Do you really want the government taking that right to fair malpractice damage settlements from citizens?

I just knew when I clicked on this that they weren't talking about my brother. Perhaps you've heard of him? He's the @!$%# with the PHD that is never wrong.

Do you seriously think insurance companys are going to substantially lower malpractice insurance premiums or your individual medical insurance premiums if some reduced payout cap on medical malpractice cases or tort reform is enacted?

Calfornia capped pain and suffering awards at $250K about a decade ago. Didn't put a dent in the premiums a Dr. or clinic have to pay for E&O insurance.

Malpractice suits are usually high because the continued care of the injured patients will be unusually high for the rest of their lives and the one/s who caused it should pay those medical bills and the patient's loss of income and quallity of life.

As with car insurance, if you want lower rates, make less mistakes as a professional group!

Calfornia capped pain and suffering awards at $250K about a decade ago. Didn't put a dent in the premiums a Dr. or clinic have to pay for E&O insurance.

Very true

The insurance companies profits have risen dramatically (and they were making great profits before) since paying less out. Caps on lawsuit settlements are backed by insurance companies to ensure outrageous profits, but do not pass on the saving's by lowering premiums.

KJR,

factors he sees that may have contributed to HIS mistake, that he acknowledges.

Yeah and all reasons he gave pointed the finger at the nurses. I didn't read one description where he wrote "I did ...” or “I should have…”

Like I said great he wrote about it. Now he's a hero for blaming the RN's and throwing everyone else under the bus.

response to jfzs...

As I answered you above, I didn't and don't see it that way, but I respect your opinion. I think Dr. Ring did accept responsibility, and I think the article shows that.

I've worked at two hospitals and volunteered at another one after I retired. If you ever want to know the real scoop, ask a nurse. They usually know who are the good Dr's and which ones to stay away from.

When I moved to Fl 23 yrs ago, there was a spine Instution with a Dr being the owner. He was always in the newspaper as preforming the wrong surgery. We moved away from that city to another one in Fl. Now after 13 years we are back, and HE IS STILL PREFORMING SURGERY!. He's even admitted a couple blotched surgeries. I can't believe his license hasn't been taken away.

However, kudos to him for letting it all out. Mistakes happen, it just what happens afterward that determines whether a lawsuit happens.

Having been the lucky recipient of a botched surgery myself...at least this doctor admitted his error, publically. In my case, the doctor left the blood supply below my waist cut off for too long -- he overestimated his ability to finish the surgery first -- and I ended up paralyzed below the waist and have been in a wheelchair since...ten years now. After the surgery I saw that doctor once when I was recovering, and I was there for a week! No apology, no communication about it at all...it was like he said, "yep, he's paralyzed...next patient"!

At least one guy admitted he made a mistake...

Humans are prone to mistakes, doctors or nuclear power plant workers are no exeption, the exception is anyone who admits his/her mistake.

I give Dr. Ring a lot of credit for going public with this. Most often, doctors lie to protect themselves and their colleagues. Yes, they're under stress to shuffle patients through because of insurance reasons and need to make up the slack with volume. Yes, they're pressured and sleep-deprived. Yes, they're human and make mistakes.

If they want to continue to be Mini-Deities (MDs) they'd better get their acts together, because making a life-altering mistake with someone's body is unconscionable.

Until gross errors are reduced or eliminated, I still advise using a Sharpie to mark and label our surgery area. We're often under some sort of anesthesia before being wheeled into the OR and can't speak for ourselves to make sure that whatever they're doing is in the right place of our bodies. My mother went in for a hysterectomy and almost had a mastectomy had it not been for an alert nurse who reminded my mom's surgeon.

We're still at their mercy with errant sponges and instruments left in our bodies "by mistake" or other surgical errors that maim or kill us.

KLR,

I think Dr. Ring did accept responsibility, and I think the article shows that.

Could you please quote me where in the article he took responsibility? Not him telling about what others did, but where he states what HE could have done differently to prevent this mistake. Please give me a quote where he talks about himself and his role in the error, what he did or didn’t do that contributed to the botched surgery. I honestly would love to read it. Thank you :)

Waiting...Anybody?

"About 15 minutes later (post surgery), while I was in my office dictating the report of the surgery, I realized I HAD PERFORMED THE WRONG PROCEDURE," Ring wrote.

(Even though he had no choice now, don't see how anyone could take more responsibility than that.)

OK so he realized it and he admitted it happened. Like the lady wasn't going to notice when she recovered from anthestisia. I am looking for his insight into what he could have done to help prevent it, have not seen it yet.

So again

Could you please quote me where in the article he took responsibility? Not him telling about what others did, but where he states what HE could have done differently to prevent this mistake. Please give me a quote where he talks about himself and his role in the error, what he did or didn't do that contributed to the botched surgery. I honestly would love to read it. Thank you :)

Waiting...anybody

Congratulations for the doc. You have renewed some trust in your profession and have shown yourself very courageous indeed. The rest of your profession should follow suit. Although, I do believe that the hospital staff share some, if not most, of the blame for this botched procedure. It is theit responsibility do the pre-ops and set-up.

I remember when I had knee surgery done that I went in with one knee marked 'NOT THIS ONE' and with the other a red target designed on it. We all had a nice chuckle when the surgeon and staff undressed the surgery area.

jfzs: Yeah and all reasons he gave pointed the finger at the nurses. I didn't read one description where he wrote "I did ...” or “I should have…”

Like I said great he wrote about it. Now he's a hero for blaming the RN's and throwing everyone else under the bus.

He stated all the "missteps" that took place. I work in a hospital; there are protocols in place that we ALL have to follow to check, double-check, triple-check, quadruple-check everything that everyone does - nurse, anesthesiologist, surgeon - to ensure that the right procedure is done on the right body part.

Where in the article does he claim responsibility? I saw it here...

while...dictating the report of the operation, I realized I had performed the wrong procedure

...and here...

I don't want anybody to make the same mistake I made

Doctors/hospitals, as with lawyers/law firms, are directly responsible for the actions (or inactions) of those who work for them - this includes the nurses, the staff, etc. It was not just ONE failure of action that allowed Dr. Ring to make the mistake he admittedly made - it was a series of missed actions that resulted in his performing the wrong procedure. Regardless of the person(s) failing to complete those actions of protocol, Dr. Ring was the surgeon, and he is ultimately responsible for the mistake. Unless a nurse, staff member, etc. performed an action with the specific intent of harming someone, when the malpractice suit comes down, it's not the nursing or administrative staff that is sued, it's the doctor and/or the hospital.

Protocols are put in place, often due to a mistake that is made, to prevent the same mistake from ever happening again. It may be a rare mistake, but the doctors develop a protocol to prevent that rare mistake because they realize that they too are human.

I'll say this, though, you think the doctor was placing the blame on the nurses...10:1, the nurses blamed the missing interpreter or the distracting computers or the shift change or the surgeons who were running behind and caused them to be moved to another OR. Most of the nurses I have encountered in my job (administrative staff) seem to think that they are as infallible as you seem to think doctors claim to be and are quick to point the finger at anyone but themselves. That is also a human trait.

I applaud Dr. Ring for having the integrity and courage to step forward and admit the "mistake I made."

Like I said not one quote to what HE did to contribute to the mistake only that it happened. Funny how a few think they are making some ground breaking point by repeating that he admitted it but not one can give me a quote of him pointing out what HE did or didn't do that caused the botched surgery and it looks like I am correct that such a quote doesn't exist. Again great I'm glad he wrote about it so others can learn but all he did was admit he did make the mistake but NOT why HE made it.

DG_W

OMG- I wish you all the best and hope that someday you are able to get up and walk.
With all the new technology there may be hope yet for you in the near future.

Sheshi
There may be protocols in place and that is where they stay. I have been in too many hospitals where I found the protocols not used and the nurses and doctors very unsympathetic and full of themselves.
I am happy to hear that where you work it is not the same.
All the best

jfzs,

Not sure why you're so intent on discrediting this guy, but the reason he made his mistake is pretty clear - he does cite various factors that led up to the mistake, but the bottom line is that he got himself confused about what procedure he needed to do for her.

That's it. He screwed up, and recalled the events that led up to the botched surgery. It doesn't seem like he's assigning blame to everyone except himself. Additionally, it sounds like there were other problems that day as well (such as other staff not verifying information as protocol dictated), so what is wrong with also bringing these issues to light?

Who said anything about discrediting…only you.

I read another account where is said The physician operated on the correct hand but performed the wrong surgery. OK why? what could he have done differently? He NEVER says.

I would like to see him talk about what he did wrong what he could have done to help prevent it, that's called insight. Funny how people talk about personal responsibility but don't understand it. His telling others what he should have could have done to prevent this will benefit the medical community as a whole.

Why are you so hung up on because he admitted it happened and pointed fingers at the staff he some how is a hero. I repeat I am glad he wrote about it so others may learn but what has he learned? He could be a great doctor. I am looking for his understanding of what his actions had to do with the mistake. Why does that offend you?

You're satisfied with him just admitting it happened.

I see what you're saying. Sorry, I had not read some of your other posts. I agree.

However, is he truly just "pointing fingers" at the staff? It is clear that they erred as well, so it is a good thing to examine their actions as well.

I'm not offended by anything you've said. I'm just a medical student who has much to learn.

Yeah and all reasons he gave pointed the finger at the nurses. I didn't read one description where he wrote "I did ...” or “I should have…”

Like I said great he wrote about it. Now he's a hero for blaming the RN's and throwing everyone else under the bus.

Maybe you should read the original article in the NEJM, instead of assuming a few excerpts tell the whole story. And I'm sure others did contribute to the error. That's why it's called a surgical TEAM.

I have worked as a part of a surgical team.
I tried to stop the removal of a wrong body part at the time it was happening and got an arm slap and a mean look glaring from over the doctor's face mask. After the doctor realized what he had done, I was told to keep my mouth shut and I later heard the doctor explaining to the family that he took out 2 parts (on opposite sides of the body) because after he "got in there" he" found other things." To the credit to the other doctors in the practice they warned him about any kind of retaliation against me, but it NEVER went to peer review. He was put on the practice's probation for taking out the wrong part - not for also lying to the patient and his family. PEER REVIEW IS A JOKE! Doctors COVER for each other.

BTW: the patient had to pay for the "extra" work done!

jfzs

I read another account where is said The physician operated on the correct hand but performed the wrong surgery. OK why? what could he have done differently? He NEVER says.

You obviously weren't paying attention when you read the article.

Dr. David C. Ring, a hand and arm surgeon at Massachusetts General Hospital, described in the latest issue of the New England Journal of Medicine how a series of personal and system-wide mistakes led him to operate incorrectly on the hand of a 65-year-old woman with a painful "trigger finger."

This is the second paragraph in the article. Further on it describes the article:

Ring's public admission is rare in a field that typically cloaks doctors' errors in anonymity, if not secrecy. Patient safety advocates praised Ring's seven-page mea culpa as a necessary step to reversing rising numbers of wrong-site surgeries and other errors.

Please pay attention.

I agree, the boards that oversee physician licensing protect the doctors and doctors protect one another. To bad a patient can't take an attorney into the operating room. Once out, a patient is defenseless and does not know anything. This is good for the surgeon but bad for the patient.

JFZS, by any chance, are you a nurse? You do sound like one. Being very defensive about all the nurses and trying to make it sound like there is no way at all they could possibly not make any mistakes. Too many nurses are lazy today and have no interest at all in doing their jobs. I cannot imagine any staff leaving in the middle of a procedure because it was time to change to the next shift. If they did they, they should be reprimanded. I have had more than my fair share of hand surgeries and have always had one nurse assigned to me who follows me through to the recovery room. I am sitting here looking at the most recent operation site and can see everyone's initials who "signed off" on what was being done and at each site. So sounds like there was a lack of communication all the way from the top to the bottom at that hospital.

Also, if that lady had trigger finger, betting she also had carpal tunnel and she ended up with a good outcome that didn't cost her a darn thing. She is probably better off with both operations and her son is the one who is pushing all this in the hopes of a big settlement so he doesn't have to work!

pbsmith,

ty for you post. I absolutely believe others contributed to the mistake. I wanted to read about his insight of his own actions as you came to understand, ty. I think you'll be a great doc!

flbikerchick,

I didn't assume anything but since this is article what I read I am addressing it, I would be happy if you would quote me from the NEJM, since I'm sure you've read it at not just assuming from this article, where he speaks of what he did wrong and how he would change it. Thanks

Michael,

Where did I not pay attention? Because you do not agree me is that your evidence? Obviously you didn't pay attention to what I wrote or you get upset when others don't see your view.

Meezermom,

I hope the woman did have a great outcome. I have no doubt many factors and people including nurses contributed to the mistake. Again, and why is this such a great sin to you all, that I would like to read about the docs take on what he did or didn’t do that would have helped prevent this mistake. Really nobody gets that? If it doesn't interest you fine, but it does interest me.

If anyone has any quotes of the Dr. Ring that speak about his actions and he would have changed them please direct me to link or paste them here. Thank you

jfvs, I think the point of flbikerchick's post was that you should read the medical article this news article is based on if you're so interested in answers. Expecting someone else to read the NEJM article for you and quote to you what exactly the doctor said to accept responsibility is just silly. If it interests you so much, go read the original article. If it's not important enough for you to do your own research, you can't really blame people for ignoring your demands for proof that this doctor took responsibility for his actions.

jfvs...

The doctor admitted he performed the wrong surgery...what exactly are you looking for? How he came to decide to do the carpal tunnel surgery as opposed to the scheduled release surgery?...obviously he made a mistake in determining what procedure he was scheduled to do. Kind of like driving to the grocery store when you were supposed to be driving to the school...how are you supposed to explain what made you make that error? Usually all the circumstances...well, the car was moved to a different location so I had to change my usual plan to include the moved location...I knew I was on a schedule so that was occupying some of my thoughts...the grocery store I usually go to is near the school... SERIOUSLY...this doctor tried to explain the chain of events that could have contributed to the mistake of performing the wrong procedure that HE ACKNOWLEDGES HE MADE...he is not trying to give an excuse or some reason that condones the mistake he made...THAT IS THE POINT.

Wow you just dont get it.

In the early eighties, I was in the Evanston (IL) hospital with sarcoidosis. A nurse came in with a pink pill "to lower your temperature." I replied that I didn't have a temperature (I had brought my own thermometer) and she looked at her tray and muttered "oops, wrong patient." I reported this to my doctor and he said heads would roll. I never heard anything more about it. Of course, the pill probably would not have harmed me, but this was an exmple of carelessness that the doctor was unwilling to let pass.

jfzs: I'm not sure if this is exactly what you're so desperately searching for from the Dr, but while I didn't find direct quotes about what he could have done to change/prevent the outcome of the situation spoken about in the article, there are things said (from him) about how to avoid this in the future:

Although he apologized to the patient, waived her fees and successfully performed the correct surgery, Ring said nothing could undo the mistake. But by writing and talking about it publicly, he hoped to break the silence that still surrounds doctors’ errors — and prevent them in the future.

“We’re transitioning from the blame-and-shame culture,” Ring said. “This is not something you sweep under the rug.”

Basically, he's saying by publicly admitting his mistake, and acknowledging it, he would know better from now on to pay more attention, and hopefully by speaking out, more Dr.'s will follow his example and fewer mistakes like his will happen.

Massachusetts General Hospital officials reviewed the error, reemphasized safety protocols and coached Ring and others involved in ways to avoid specific mistakes in the future.

“I hope that none of you ever have to go through what my patient and I went through,” Ring wrote to his medical colleagues. “I no longer see these protocols as a burden. That is the lesson.”

Here it says he went through reviews of protocol with hospital management/safety instructors along with the co-workers who were involved in the incident, to minimize the risk this, or other incidents would repeat and acknowledges to his colleagues that he no longer views the safety protocols as a pain in the neck, so (IMO) he's learned from this. I think people need to not jump down the Doc's ass, and realize that he's owned up to his mistake and taken the steps to review safety protocols to insure he won't mess up anymore patient's surgeries again.

I didn't find direct quotes about what he could have done to change/prevent the outcome of the situation

That was it, that's what I'm searching for. Since you did look for the quotes I guess you did know what I was looking for and I thank you for that.

This is what I found http://www.nejm.org/doi/full/10.1056/NEJMcpc1007085

This is an article from The New England Jouranl of medicine. I Just found it and have a busy day so I will have to read it later. Here's the link again if any one wants to read it.

http://www.nejm.org/doi/full/10.1056/NEJMcpc1007085

It's long but if anyone is interested in more deatils than the MSN article here it is :)

Case 34-2010 — A 65-Year-Old Woman with an Incorrect Operation on the Left Hand

David C. Ring, M.D., Ph.D., James H. Herndon, M.D., M.B.A., and Gregg S. Meyer, M.D.N Engl J Med 2010; 363:1950-1957

My mind-set at the start of the day was, “I have three big procedures that I have specifically planned and prepared for and a few 'carpal tunnels' to perform today.”

Stress on the day-surgery unit was high because several other surgeons were behind schedule.

The change of rooms also introduced a delay, during which I went to an inpatient floor for a consultation.

Another patient who had been upset about the injection of the anesthetic for her carpal-tunnel release had become very agitated in the recovery area. Although I was able to help put her at ease, the encounter was very emotional, producing in me both the cognitive and physiological aspects of anxiety.

I spoke with the patient in Spanish, which the circulating nurse mistook as a time-out. and as a consequence, no formal time-out took place before the procedure was begun.

I performed a carpal-tunnel release on this patient, rather than a trigger-finger release.

I apologized and explained that I could perform the correct procedure if she wanted me to do so. She agreed.

I then performed a trigger-finger release, without complication. The patient was discharged home that day after a brief recovery.

The article is lengthy but the above is the only part Dr. Ring contributed to the article was the events of that day. The rest of the article is written my several specials of how events like this occur and the history of tracking them etc…more below on that

From the article

How could this have happened to Dr. Ring and his patient?

Breakdowns can occur in skill-based behavior, rule-based behavior, and knowledge-based behavior. In many cases, such as the wrong procedure described here, all three occur.

Breakdowns can occur in skill-based behavior, rule-based behavior, and knowledge-based behavior. In many cases, such as the wrong procedure described here, all three occur.

the appropriate response to the persons (in this case, Dr. Ring and the others in the operating room) who are associated with an event involving the safety of patients is to coach, not discipline. Such an approach may lead to a more forthcoming culture, in which persons are likely to report events that compromise patient safety, and thus provide an opportunity for learning and improvement within an organization.

DG_W

OMG- I wish you all the best and hope that someday you are able to get up and walk.
With all the new technology there may be hope yet for you in the near future.

Unfortunately that's extremely unlikely. Since that surgery I've become Type II diabetic, and because that surgery left me with diminished blood flow below the waist when I developed sores on each of my feet I had to have both legs amputated. Because of the blood flow issues it was deemed very doubtful that I'd heal from the surgery, and as a result both legs were amputated above the knee. Add to that the fact that I had had a stroke six years before the surgery and the chances of my walking again would depend on a "Star Trek" type technology leap ahead.

That's OK though...I've told many people that as long as I have my brain and one arm/hand to use a keyboard with -- which I do -- I'm fine. I'm a happy person at heart, and it will take more problems than that to get me down. But I do appreciate the sentiment!

I truly applaud Dr. Ring for his courage in writing this article. Hopefully this will set a precedent for others to follow.

BTW, last time I was hospitalized, not only was I misdiagnosed, but my records were falsified to make it look like I received care that I did not receive. In reality they almost killed me and gave me no treatment at all-actually treated me worse than a dog. If you look closely, you can see the inconsistencies in the chart. You can see the histories supposedly of me supposedly gotten from my husband given in doctors' evals that are obviously made up (ie, they have lots of incorrect information from my education level to my recent history-one says I went to a clinic in New Orleans, what the???- to my reason for hospitalization)-though not made up enough to be a different patient. No, enough of it was correct that it was definitely me-ie, I did go to a minor emergency place in Myrtle Beach.

A little more: that doctor gave my reason for admission to the hospital as I "didn't know what to do with myself." The actual reason was for pain control due to a severe, intractible migraine and b/c I was immediately post lumbar puncture. When he evaluated me, I was practically in a stupor from dehydration b/c they refused to give me fluids or nutrition, saying I had to get up and "help myself" despite having an undignosed spinal headache on top of the migraine at that point. It was such a nightmare! I was alone, not by choice, but because my husband was incapacitated as well.

How's falsifying records for covering mistakes?

Dr. Ring did not write the article. He contributed a paragraph about the events of that day. Otherwise the authors wear going to write about the case using no names. The article the authors wrote about was really more about the history of tracking these mistakes etc...

Assuming you had evidence of your claims, if you didn't have money to file a lawsuit, how are you going to defend against a libel suit? You two have just publicly named a doctor and made allegations against him without backing them up with evidence. If he or his estate choose to pursue this, you could have a lot of trouble headed your way. Very irresponsible.

Obama care....Here we come!

I'd rather have Obama care then Republican care which is absolutely nothing!

About the doctor, we are always taught to learn from our mistakes, but if they don't ever admit their mistakes how will they ever learn from them. I applaud this doctor for doing the right thing.

Hope you didn't vote for Obama, cuz that's what we are going to get here soon. I talked to a friend in Canada that told me after he figured out all the taxes he had to pay, that his free Med insurance cost him $17,00.00. You have to wait and wait and wait to see a doctor. Nothing is free.

This is America! I can vote for whom ever I want to. a--rand do you know what hearsay is. Go ahead and tell me again what someone else told you. What an idiot.

Darren, I'm pretty sure that the reason we go to history class is to learn from what someone else tells us so we don't repeat the mistakes of others. A wise man learns from others' mistakes, a fool (i.e. idiot) from his own.

Lessons from history class are researched by many people so errors are eliminated. Accepting a statement from just one person about what one other person told them with no other evidence is just plane dangerous.

a..rand

I talked to a friend in Canada that told me after he figured out all the taxes he had to pay, that his free Med insurance cost him $17,00.00.

I seriously doubt that and you have nothing except second hand information to support the claim.

You have to wait and wait and wait to see a doctor.

No you don't. That is a myth perpetrated by ignorant people such as yourself.

Nothing is free.

You live a seriuosly deficient life. If you can't find something that is truly, truly free, then you are spending way too much time in a bar watching Beck!

Sorry to hear of your misfortunes.

Probably wouldn't have done any good to try to file the lawsuit anyway. I tried, after the year and a half of constant pain, and was told by both the drug companies, lawyers and doctors, that I didn't have a case. They all passed the buck. I sure don't see where all these so called mal practice suits get anywhere. I don't believe there are as many of them won as the dishonest incompetent doctors or the greedy, dishonest insurance agents would like for us to believe. They're just working so closely with crooked lawyers, judges and legislators ( many of whom are insurance agents), that the average citizen has no recourse, and no one in either the medical or insurance field is held accountable.

why did she have Dr. Ring then do the correct surgery?.... because she doesn't have a third arm.

Lin, there was NO lawsuit. Dr Ring was upfront about it ... the patient had tendons in her GOOD (and most probably writing & eating hand) hand permanently and irrevocably cut and made useless and will most likely have movement issues with what was once her good hand before that erroneous surgery.

Dr Ring was indeed honest and upfront about it which took alot of courage, but a person was maimed with a surgery she didnt need on that right hand. After that surgery, she still didnt have her issue that brought her to surgery accomplished and resolved, so yes, she gave him permission to do the correct surgery to resolve the pain that brought her there to begin with rather to continue to suffer with the issues that brought her there to begin with while searching for a new surgeon.

Once the Dr revealed all to all concerned, apparently the hospital "settled" the mistakes by not only Dr Ring, but the complete surgical team. This wasnt one person's mistake, but a surgical team of the hospital's staff. Not only did they not verify what they were doing when that mark was missing, not only were they not paying attention ... they preformed a surgery that was NOT scheduled. Th original surgery wasnt for "carpel tunnel" ligament issues, but a "trigger finger" muscle issues.

Whatever the settlement, that is their business. The woman was unnecessarily harmed and deserved restitution of some kind. The Dr was honest enough and has the integrity to state facts on behalf of his patient's best interests, so he informed all, including the patient.

Surgery of any kind is hard enough to emotionally and psychologically prepare for in the first place, imagine the nightmare of waking up to find out you didnt have the surgery intended and they went into your body and did something totally unrelated to why you were there to begin with.

An extreme thought, but think of it carefully. You are 23 yrs old, newly married and are admitted to have your tonsels taken out. When you awake in recovery, you discover they made a mistake, they removed your uterus in error and the woman with uterine cancer had her tonsels removed instead instead of her uterus. It turns out they played musical rooms for whatever reason while preping for the surgeries and "lost track" of which patient was which. Would it be ok to merely say oops, or attempt to blame the two patients for their negligence and then avoid responsibilities for the errors, or do right by both of them? Does an error have to be that dramatic for a patient to obtain sympathy and public outrage for the fact they were unnecessarily medically harmed?

Recycled,

there was NO lawsuit

How do you know there was no lawsuit? It didn't say one way or the other in the article?

Whatever the settlement, that is their business

You may think it's their business but that's what newsvine is a place for, people to voice their thoughts and opinions right or wrong, just as you did.

The woman was unnecessarily harmed and deserved restitution of some kind

Lin didn't say the woman shouldn't receive restitution

Recycled Hope...

Great Comment. Thanks for some good logic and insight.

Recycled Hope --

Where did you get your information from on what is involved in carpal tunnel surgery? It most certainly does not involve permanently and irrevocably cutting tendons and making them useless.

Carpal tunnel syndrome occurs when there is pressure on the median nerve, which, along with several tendons, runs from your forearm through a small space in the wrist (the carpal tunnel). The median nerve controls movement and feeling in your thumb and first three fingers.

During surgery, the doctor cuts the ligament at the top of the carpal tunnel. This makes more room in the tunnel and relieves pressure on the nerve. In most cases this relieves pain and restores a great deal of function to the hand.

Additionally, the article is a little ambiguous as to whether the first surgery was performed on the right or left hand. (The article was updated to correct information about the surgery, so it's questionable what the complete information is. Have to check out the NEJM; more reliable than MSNBC.)

In my opinion, those who consider her to have been "maimed" by the surgery have no idea of the nature of carpal tunnel syndrome and its treatment. (Yes, I've had the surgery.)

Just me says..."During surgery, the doctor cuts the ligament at the top of the carpal tunnel. This makes more room in the tunnel and relieves pressure on the nerve. In most cases this relieves pain and restores a great deal of function to the hand."

Even when there is no pain caused by carpal tunnel...no pressure on the nerves...and no need to cut a ligament, you think this surgery would have no negative effect on function or resulting chronic pain? I would question that.

Additional note:

The New England Journal of Medicine article indicates that the carpal tunnel surgery was performed on the left hand, which had been correctly marked as the surgical site.

The patient followed up at a clinic associated with the hospital. "A financial settlement was negotiated shortly after the event." (NEJM)

Just me,

Thanks for real info! Appreciated

I love how so many of you make comments and sit in judgement. If you had even the slightest clue of the stressors involved with providing care for human life you would not say a thing. Humans are prone to error and the last thing I ever want to do is make a mistake however they are inevitable. The beauty of mistakes in most other professions is there is no where near the same reprecussions. We operate every day with the risk of losing everything due to human error, lets not even talk about the emergent appendectomy at 3am.

KJR-

The ligament cut is called the "flexor retinaculum", and its primary job is to contain the forearm flexor muscle tendons, as well as the median nerve, within the "carpal tunnel".

Cutting through this ligament does not typically cause any overt functional issues, but it is obvious that this ligament is important nonetheless. Yes, some people have impairment after the surgery, but it is no different than the post-op consequences of any other procedure.

True, this woman may have some functional/symptomatic issues after the mistaken surgery, but it is not likely that it will result in any significant problems. Hopefully. In fact, most of the time when people have CTS surgery but still have pain and symptoms, it is because the surgery was not successful, and therefore the person's pain is generally due to the initial CTS condition itself. Of course, with any surgery, there is always the chance that secondary issues arise. Surgery is a gamble either way.

So, my point, KJR, is that this woman may have problems as you mentioned, but it is not likely that they will be severe or debilitating.

Lastly, I would like to mention that if anyone has CTS, I would recommend they seek out chiropractic care and physical therapy FIRST, before going "under the knife". These therapies have a good track record and are relatively non-invasive.

Indy Patriot...

Thank you for that informative post, and now with further information concerning this case, indicating that the surgery was performed on the correct limb...wrong procedure, I am guessing there would be little long term negative results, and very possibly a more positive outcome, as well. We aren't given information such as what Dr. Ring found when he got into the surgical site...maybe his findings supported the need for the carpal tunnel procedure and thus further reason that he did not question the procedure even at the time he was doing the surgery. Orignally, I believe the article seemed to say he operated on the WRONG limb, which was a part of my thought that negative consequences to the patient may be greater. And I was defending the point that the patient did or may have suffered some negative effects from the wrong surgery being performed. That was not an attempt to attack or heap blame on the doctor, or anything.

At any rate, I respect this doctor very much...especially knowing, if the further reports are accurate, that the procedure was performed on the correct limb, it would have been easy for him to cover-up his mistake...lie to the patient and claim (as in comment #1.43 above situation described) that once in surgery, he discovered the additional surgery needed to be performed first, or something like that. That is very often the usual part of a cover-up response of medical care givers in these type of medical mistake situations, I believe. I admire the fact that when HE caught his mistake, he immediately acknowledged it, including to the patient, and is trying to use the unfortunate mistake to bring awareness and prevent future similar mistakes. As I said before, I would feel more confident going to this honest doctor than many of the "respected" medical care givers out there.

LOL You actually sound like a very believable "niche" responder here.

Hmmmm....If you had a surgical instrument left in your abdomen, I'm sure you'd change your tune!

Wow that is extreme. When you make such generalized statements you give us Republicans a bad name. Republicans aren't always right just like Democrats aren't always wrong. Do you have all the facts or are you just spouting off information based on the information that is is front of you. Judge not least you be judged!

There are mistake and then there is negligence. This, as much as he should be applauded for coming out, was pure and simple negligence. If you read the story there were many checks that failed. It also does not say what the effects of the wrong surgery had, not to mention when he was performing it he did not notice the lack of need for the release on the wrong hand. Yes doctors make mistakes and the legal system is screwed up, but there must be a remedy when negligence occurs and people suffer.

Martyks --

Nothing in this story suggests that this patient is a "welfare mother". She is a 65-year-old Caribbean native. Whether she has children or not is immaterial. Nothing indicates that she lives in the United States. There are many people from other countries who come here for surgery.

Please show a little respect for someone about whom you know nothing other than what MSNBC told you.

Incidentally, the carpal tunnel surgery (whether done on the left or right hand seems to depend on which version of the story you read) will most likely improve the function of whichever hand it was done on.

Further note:

The NEJM article indicates the carpal tunnel surgery was performed on the left hand. The proper hand had been marked, as Dr. Ring had observed when he translated during her preop preparation, although the exact site for the incision was not indicated. The marking was removed by the alcohol in the solution used to clean the arm and hand in the operating room.

Martyks, you had to know there would be those who are in such a hurry to prove themselves better than you that they wouldn't read all the way to the end. You did that on purpose, didn't you?!

Unfortunately though, lawsuits can't be filed against these two bit foreign flesh cutters who insert themselves here either. They come here and "play" doctor and basically do what they want and amass their little fortunes, and we're expected to let them get away with whatever they want. If you really truly don't mind being butchered then let me suggest a "doctor" for you. Try "Dr" H.M. Ramesh in Charleston WV. That should be a hoot. And this quack still "practices" here, because he was allowed to get by with his lies and deceit. He makes mistakes every day, and patients cry in his office every day from pain and suffering. He told me, on my last visit, that " if you make anymore noise(crying) in my office, i not tweet you anymore. Well, I decided right then, that this butchering quack and fake, would not tweet me anymore, but still he is doing it to other people. The entity, (he's not worth being called a man) got away with it, as many of these butchers are every day. He is a disgrace to the human race, let alone the medical professions. Trivial lawsuits? Not on my part. I couldn't even file a legitimate one.

Exactly what I was thinking, bitter! Anne, James, Stu, consider yourselves PUNKED!!!

Ditto. as an RN, i am disgusted with the RNs' not followng policy and procedure. Could it be the RN;'s were new on the job and did not know or care what they were doing??? What a surprise!!!!!!!!!!!!!!!!!!!!!!!!

As an RN you should be a little more respectful to not blame the RN's for this happening. Maybe the fault should lie in the fact they did not take the time to get a hired translator in there, and I am disgusted by you ASSuming they do not care. Learn a little more respect for our profession and fellow RN's. That is why we have a bad name, because of nurses like you. Better yet come here to the USA, learn ENGLISH!

aessary,

What are you talking about. You blame the patient for not telling the surgeon how to operate? Feel sorry for your patients who are unconscious, you'd probably just take them out back and bury them.

rrobeson,

where in my statement does it say it is ALL the patients' fault? I blame the entire system. Every step was done wrong PERIOD.

No need to feel sorry for my patients, they are in very good hands. I have stood up to numerous doctors looking out for what is best for my patients because I am the one spending 12+ hours a day with them. I am a post surgical nurse so I ensure my patients are not unconscious!

You never blamed the pt! Rob needs to learn to read.

I applaud the surgeon for taking ownership of his grave error

The doctor only wrote about it, but he blamed the nurses and system. show me where he ever said he did anything wrong.

I would LOVE to hear the Rn's story of what really happened.

I cannot believe that a fellow RN would diss his/her profession like that. There are steps to assure that wrong site surgery does not happen, which should have been taken. It appears that there was confusion on all sides. I have been in the position where I have had to change patients/rooms, but am always sure that I do a "time out", no ifs and or buts. Everyone is to be quiet and listen to the circulator, and the CRNA is to be looking at the armband when the circulator is reading the consent. I even had a doctor look at me and say "Well, we all know she can read." and I just looked at him and said "Thank you." I am an OR nurse and am a patient advocate. I have gotten in arguments with the docs and anesthesiologists to protect my patient. I respect this doctor for owning up to the error, and admitting it in public. He could get a lot of flack about this, but I think he did the honorable thing. Sooooo...to all the RNs reading this...keep up the good work! We do a lot, have a very stressful job, and at times we don't get the respect we deserve...be it either from doctors, patients, or family members.

I cannot believe that a fellow RN would diss his/her profession like that

I agree.

I'm not a nurse, but I think making a healthcare professional work 12 hour days is just begging for an error like this to occur. In studies of manufacturing it's been demonstrated that after having an employee work 10 hours there is a huge drop in productivity.

The vast majority of nurses want 12 hours shifts. It actually is better for continuity of care and it's hard enough to get 20 hours worth of work done in 12 hours let alone 8.

The doctor only wrote about it, but he blamed the nurses and system. show me where he ever said he did anything wrong.

Maybe you should check out the original, entire article in the NEJM before passing judgment.

This is available this is what I'm commenting on just nearly everyone else on this thread. But when others posters agree with you, you don't care if the read the NEJM. Hypocrite?

jfzs: "The vast majority of nurses want 12 hour shifts."

Hilarious ,so source please.

My mom was a career HEAD NURSE at Mass General and after 8 hours on their feet daily on those hard floors - ALL of their legs ached and caused varicose veins -for one thing, and pain is not conducive to good concentration and care.

(I use the term "their" legs since over many decades she used to bring many of the staff RNs home for dinner etc. and I would hear their discussions. They ALL complained about aching legs. Called themselves PAWs, so you know it's true - IF you are in the medical field, which I highly doubt.)

Exhaustion and pain is when your MEDICATION ERRORS also go off the chart.

Only a non-nurse would ever say such a thing. LOL

LOL so if someone has a difference of opinion from your mom they couldn't possible me a nurse LMAO now that was funny

BTW depending on the unit hopitals also offer 8 hour shifts

mcah, I wouldn't get your panties in a twist because RN's forget certain protocol's. I am not a nurse, but I am a 29 year old with a disability and have been in and out of the ER, hospital, and OR, so often I'm starting to be on a first-name basis with some of my physician's. I know details about the private lives of some of the RN's I've been treated by, and I even know the names and ages of some of my physicians' kids.

I've been in the ER/hospital/OR setting so often that RN's actually have told me that I should become an RN... Skip the courses and just take the state medical license exam - with all my knowledge and experience I'll pass. LOL.

But anyway, I told you that personal story about me to tell you this: I have seen nurses work 8, 10, 12, 16, sometimes up to 24 hours in a row when they get short-handed, so I can see how nurses can be exhausted by the end of the night and might forget to perform a safety check here and there. That's why technology is improving in the medical industry so things like medication errors, allergy reactions, OD's and things of that nature don't happen.

The job of an RN isn't all that easy: they have bitchy patients who think they know what they're talking about (and rarely do), they have egotistical MD's who also work long hours and have many patients (and can sometimes confuse one for another) and ABSOLUTELY DETEST being corrected by their RN's even at the expense of patient safety and think they can't make mistakes, then there's the patient's relatives who want their loved ones to get better two days ago and want to know why they're still sick (or worse off than when they showed up) and are taking it out on the RN because the Dr is nowhere to be found (because they're too chicken-$h!t to face ticked-off relatives.

RN's do a lot to help out their patients and don't get enough credit from their patients, the Doctors that order them around, and even their colleagues who come here with some anonymity and dump on them for slipping up on protocols when they're exhausted after working long days.

Don't get me wrong though - RN's are human just like everyone else, and I've had my fair share of problems with RN's violating safety protocols, but in a lot of cases, the responsibility of patient safety (IMO) also lies with the patient. If you're not talking to your Drs and RNs and always asking what is going on with your case, what treatments you're having, what meds they're supposed to give you and when, you're just asking to fall victim to mistakes - Of course the exception to the rule is the obvious patient that is physically/mentally unable to do that for whatever reason, but then they should have a family member or power of attorney with them always making sure they're alright - I know I would.

As for trips to the OR, I always decline anesthesia until after the "time-out" is complete so I can make sure all the medical staff is on the same page before I'm out of it. It reduces the risk that I (a male) come out with my penis still where it goes, and without breast implants! ROFL!

As a PT, I've always said and believed that nurses work harder than anyone else in the hospital. However, you guys are human, just like all of us are. You complain about doctors acting like gods, but are you any different if you won't acknowledge that you sometimes do make mistakes? I know we PT's make them. Sure, when we shop talk, we talk about how much smarter we are than doctors-but in reality only about the things we really are smarter about such as rehab or things we pick up b/c of spending more time with the patient. We, or at least I, know that doctors know much more about medicine than we do. (DPT's do know more than I as a BS in PT know about medicine.)

I've had nurses almost kill me. I've had them ignore me when I tried to tell them I was dehydrated after 48 hours without fluids-which they were well aware of. I've had them tell me they refused to help me when I needed help. I heard two of them in my room talking about a man who had coded in another room and wondering aloud if maybe it had something to do with the fact that he was supposed to be on oxygen and wasn't on it at the time! Meanwhile, my roommate was suffering from extreme diarrhea and refusing food and receiving no treatment for it for days and days. Nothing at all was done for her until I spoke up for her (she had literally begged me for help); then it was discovered that she had rotovirus. Only then did she receive treatment (immodium at least), when her daughters raised Cain.

In no way am I saying all nurses are like this. I certainly don't think they are. Like I said, I think nurses work harder than anyone else in the hospital. It just seemed like there was an incredible defensiveness, like I couldn't dare question anything or my care got much worse. The only way I got care at all in that particular situation was to give much praise and credit and to barely slide in the question sandwiched in between. (ie, they were the best at bedpans of any hospital I had ever seen-truly.)

The very same thing happened to me and I was the surgical nurse that use to assist this doctor prior to my procedure. The cover up made me sick and the devastation that I left my family in was unreal. It took us a long time to recover. Needless to say the apology never came! But the bills sure kept rolling in.

Pearl- so sorry to hear about your botched surgery But, don't give up trying to find a good attorney. They're out there though you may have to look harder in Utah I'm a Republican, I despise ambulance chasing lawyers, but in your case you deserve proper medical attention and a just settlement! Good luck and God Bless you.

Pearl-

If you believe that no attorney wants to take on your case because "its useless to fight the system" then there must be something else here that you're not mentioning. As an RN who worked in medical malpractice defense for five years, I can assure you that if your case had even the slightest of validity, some attorney would take it. Actually, many plaintiff attorneys don't have to have any solid facts to file suit and they don't even require you to put up any $$ for their services since they know they could have guaranteed 33-40% of your settlement. Plus-experts that would testify on your behalf don't have to come from Utah-in fact they usually come from other states.

khtrn --

Yes, the attorneys will take your case for their 33-40%. However, you are responsible for all costs along the line, including the charges by those experts from out-of-state. Every phone call, copy, paper filed, as well as expenses like transportation, etc. are yours as they occur. Then, if there is a settlement, the attorney takes his/her cut.

khtrn...

I fully believe Pearl and know situations such as hers (and Anne M's) are possible and do happen...way more than most people realize. I am also an RN who was injured and suffered medical malpractice/cover-up and the inability to get an attorney to help. In my case, I was injured leaving the hospital I worked at and was taken to the ER there...the beginning of my nightmare. The emotional and financial toll on myself and my family has also been horrible and devastating in many ways. And people like you, Khtrn, who state such nonsense as, "I can assure you that if your case had even the slightest of validity, some attorney would take it." only serve to add to the pain and discrediting of victims...and are a part of the problem. And as for your statement "experts that would testify on your behalf don't have to come from Utah"...most likely Pearl never even got to the point where an attorney was looking for "experts to testify on her behalf". Trust me when I tell you, no matter where you go, your social security number tells any medical care facility everything they need to know, and you will get the run around and refusal to diagnose the truth of the matter, if strong enough incentive to discredit you exists. Maybe if you worked on the other side for a while, you would learn something about what victims endure in trying to get help. As one government court mediator told me, "there is no truth in the law".

Good luck to you Pearl and Anne M.

Pearl-738543

OMG It just does not end the needless surgeries the suffering they entail.

I wish you all the best and hopefully good health.

Alcohol removes permanent marker - did we miss that sentence??

What a great idea. Why didn't I think of it?

Believe it or not, you can remove Sharpie marks with alcohol. Happens, which is why the "time-out" is even more important than most people understand.

Permanent marker on skin is soluble in isopropyl alcohol, which was used as a pre-op rinse.

First of all... she was JOKING. Second, while it does come off with alcohol... it takes a little effort. You'd have to WANT to take it off. Which means that you would have to notice the markings. Which means that someone removed the correct-side-indicator and didn't bother to tell anyone. The buck may stop with the doc... but it started with someone else.

As as for being left with debilitating injury... it was carpal tunnel surgery. If anything the wrong hand probably felt a little better (after recovery). Not saying it's a GOOD thing... but she wasn't left an crippled invalid for the rest of her life.

As for suing the hospital... it's the threat of major losses from a lawsuit that keep hospitals from creating higher risk environments. Frivolous lawsuits and extreme rewards need to be addressed, but we still want that fear hanging over the administration's heads.

Permanent markers are not used as they could tattoo the site should the incision extend over the marking. There would then be an issue with a disfigurement.

I find it interesting-because I'm a nurse. There are surgical markers used to mark surgical sites-their marks are incredibly difficult to remove

Dr.'s need to be held accountable, reducing the cost of malpractice claims, a cap of what can be paid out, is giving Dr.s a free pass, they need to be under tight rules and regulations.

They so use permanent marker but the prep solution take is right off. I know, I am an operating room nurse.

As a RN for 50 years (in the OR), and luckily,never involved in a wrong site situation, I wonder where the pre-op dept had placed the woman's IV (It should not have been in the operative arm) and the admission office had placed the ID bracelet (which also should have been on the non-operative arm!! These are a couple of clues that can help avoid wrong site mistakes. I have had to stand my ground on some issues (not wrong site ) but was later thanked by the surgeons involved. It is all a matter of team work and treating all patients as though they were your mom or dad.

Mary

It is nurses like you that make me comfortable in letting the docs gas me to sleep..lol

you realize it is the fine/small details that save alot of problems

=)

According to the New England Journal of Medicine article, the correct hand was marked, which he saw when he helped with the preop prep. The carpal tunnel surgery was done on the left hand, then he followed up with the correct procedure on the same hand. And, yes, the marking was wiped off by the alcohol in the operating room, but he had already seen it.

Everyone keeps saying about how the permanent markers "come off with alcohol", but in reality most permanent markers actually use a xenthol base as a solvent, so something like Lysol would (and does) remove it far easier.

Even so, it can not remove the full stain from things like absorption into skin, swede, silk, or satin.

I give him credit for being open about it and trying to fix it. If more doctors fessed up to wrong doing and voluntarily did things to make it right again with fair amends for damages, then the courts wouldn't have to be clogged up with their attempts at thwarting justice, and it would also save taxpayers probably billions in court fees alone.

You're getting a lot of upvotes but if you actually read the article it wasn't a wrong site surgery but the incorrect surgery performed on the right site.

It wasn't the wrong hand/finger; it was the wrong type of surgery for the problem. Magic marker would not have helped.

I had surgery on a couple of toes a few years back and I personally marked them with a marker myself in pre-op. The doctor did surgery on those toes that I'd marked, however, it was the wrong procedure. He was supposed to remove a bone spur, but instead removed entire joints. There was no going back and fixing it. Worse was he refused to admit it was an error. I'm still furious.

Surgeons only mark an extremity or side of body. A mark would have made no difference regarding this surgery.

JACHO as found that surgeons write there initials on the site does reduce wrong site errors. Although, this surgeon performed the wrong procedure, wrong surgical site, but correct side.

A mark would have made no difference regarding this surgery.

Your right, probably wouldn't have helped since he performed the wrong procedure.

The surgical site is to be marked with a permanent marker, not ink. The mark is to show when the patient is draped for the procedure. On consents, everything should be written out instead of using (for example) RUE or RLE. I have never had a case where the permanent marker was taken off during the scrubbing of the site to be operated on.

Yes it does make you wonder if it was placed at all to be removed so easliy, or with what. I work on the clerical, not clinical, but still catch mistakes of physicians or even patients who later realize that they might want to proffer more information. This is why before anything we are all to check and recheck until completed. But safeguards are ONLY as good as those who use them.

wow...what are YOU smoking?

Boy, that must have been some good stuff!

I was in Wells, Maine with my 93 year old mother who needed an x-ray on her foot. Since she's memory impaired, the x-ray technician had another technician go into the x-ray room and hold her foor still. Then she needed a hip x-ray to make sure a hip problem didn't cause her fall. The technician for my Mom came out and said she needed me to help keep my mother's side still for picture. I said, "I'm not going in there!!" She replied, "Well, I won't be able to finish the x-rays for your mother." So I acquiesed and went in as I didn't want to be the reason my mom wasn't diagnosed crrectly. When I went in, I still complained that I couldn't believe I was "doing this". I then mentioned I was worried about exposure to my thyroid as I know many women can have problems with them and I knew radiation was not good. The technician gave me the apron and mentoned many family members have to help with x-rays for family. THen took the x-ray of my Mom's hip. A stream of white fire appeared before me as hip x-ray took place. Very unnerving to say the least. When my mother and I returned to our room, I explained my disgust to a nurse. She said, "Didn't the tech give you a throid shield?" !!!!!!!!!!I said, "NO!" I never even knew they had those! I don't work in the medical field!! So, what if something happens to me 10-20 years from now (I'm 60) resulting from radiation??!! How many stupid instances like the one I went through may now be accounting for many of the cancers, etc., that are killing people?? Who can prove anything?? Especially when it happened so long ago. I spoke with head of imaging at York Hospital and, of course, she said no harm was done, although the thyroid guard SHOULD have been given to me~especially since I brought up the concern. I am thinking in speaking with the president of the hospital.

What "stream of white fire"? X-rays are invisible to the naked eye. Also, yes, family members are asked to help hold the patients instead of the tech. You helped hold your mother for one x-ray in 60 years. The tech does dozens of x-rays a day for around 40 hrs a week. That one exposure with you outside the primary beam would have given you less radiation then you would receive flying by plane across the country one-way.

I apologize if that sounded harsh, while a thyroid shield may have let you feel better you should have been outside of the primary beam and as I stated above received such a small dose that any interactions the scatter radiation had with your body would have been already fixed by hormesis.

I am an xray technician in Illinois. Most often when family members help position a patient... and it happens often.... an apron like you were offered is given to the family member. Thyroid shields aren't typically offered, but since you stated your concern the tech should have been more considerate.

Fortunately for you, the level of radiation used in a hip x ray is reasonably low. Complications from radiation exposure are fairly rare, and instances are higher when an individual is exposed at a younger age. Since you state you are 60, your risk for developing any complications from one hip xray are very rare. Remember, us xray techs are often in the room holding pts in position. Studies show that the risks for developing radiation induced complications for xray techs are equivalent to the rest of the general population. Also realize that you are exposed to radon (a type of radiation from the earth) daily. The dose you get from this exposure yearly will exceed the dose you received from the hip exam.

As for the stream of white fire... there must have been a MAJOR equipment malfunction. Xrays are colorless, odorless, and cannot be felt. The only light coming from the xray tube is called a collimation beam and is a lightbulb situated inside the tube housing which is used to properly position the tube over the area of interest. I have been taking xrays for several years and have not once seen "white fire" during the course of my workday.

No doubt you had fibroids, but with a hgb count of 6.4-the immediate need WAS a transfusion-then the cause could be determined. That reading is nearing life threatening anemia. Your 1st doctor was correctly prioritizing your care.

taxbite, then move overseas..

Doctors are not more careful because they fear lawsuits. They are in medicine to help people. They are not gods. They are human and suffer when they make mistakes that hurt their patients.

I absolutely agree with you. A Doctor or any professional for that matter that has learned a mistake this way, is significantly more likely NOT to make the same mistake again on me or anyone else. I am ALWAYS leery of those who "don't make mistakes". That means they might make one at my expense or learn on me. But one who admits they have made mistakes is less likely to repeat the error. Kudos to this Doctor and I personally would seek him out.

Yes but the patient who only speaks spanish feels differently, exactly why was not in the information... maybe something was lost in the translation.

Although if it had been me, the reality is I would feel differently perhaps even with the doctors unprecedented candor, I think feelings of distrust would be high.

Certainly we all feel for the doctor and appreciate his candor, I personally believe in the doctors truthfulness and would most likely let the man do surgery for me if I needed it.

For a double hernia was the most serious surgery I ever had.

It's not the patients fault but it does underscore the cold, hard, reality to live in America one should speak and understand English and really, read and write it as well.

An immigrant wants to come here to live, we are not going there to live nor forcing anyone to come here..

The article only stated that the patient is a Caribbean native. I don't believe it indicated whether or not she lives in the United States.

Because this doctor was willing to admit that he made a mistake and was willing to take the necessary classes afterward and do whatever else it took to rectify his error I would be much more willing to consider him for doing surgery on me if I needed it. He is not likely to forget what he did and will be far more cautious in the future since he made a mistake and admitted it.

If she was not a citizen, I wonder if he would have been stiffed for the bill even if he had done the first one correctly. Reality is that US citizens with medical insurance get charged as much as we do for things to cover all the deadbeats who come in for care and skip out on the bill - most of whom are not citizens and are here illegally. It's a serious problem plaguing our hospitals and emergency rooms driving up all of our costs, and since they can't legally turn them away, ultimately someone has to pay.

I agree also. He will now be hyper-vigilant. I am not excusing what happened, and neither is he. He has done the right thing by admitting this so the process can be looked at and changed to prevent this from happening again. I do understand that medical mistakes can be costly or even deadly but by making an environment where someone can admit things like this without losing everything helps fix what went wrong to prevent it in the future.

Site your source for the statistics please

Cite.....

This source claims that iatrogenic illnesses are the eighth leading cause of death in the U.S.:

http://www.deathreference.com/Ho-Ka/Iatrogenic-Illness.html

I would trust him for a couple different reasons. First, he is honest, he admitted the mistake and wants to make sure others don't make the same mistakes. He also will follow protocols and safety procedures to the letter.

Wow someone who actually wants sources rather than swallowing anything anyone says! Good for you Jester13. here's your sources:

In the July 26, 2000, issue of the JAMA, Dr. Barbara Starfield documented that over 225,000 deaths each year are due to iatrogenic causes.

In the USA alone, for instance, it is estimated that medical mistakes in
hospitals have killed 7.8 million Americans in the last decade. This is more
than the combined casualties of all the wars the USA has fought in its
entire history. (Gary Null et al, Death by Medicine)

For more eye-opening information on the nature of modern medical care, with the focus on cancer "treatment" read "Cancer - Step Outside the Box" by Ty Bollinger.

Prepare to be completely astounded.

Here is something more astounding. When doctors go on strike, mortality rates, in hospitals, decline. Our expectations of doctors sometimes exceed their abilities.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1127364/

Thats because people stop going to the hospitals when the doctors arent in......duh.

claudicate...have you heard of educate? Your comment makes me think duh is all you can comprehend.

also claudeicate, do you think there were no patients in hospital beds during the strike? Think before you bark, please.