Wednesday, November 10, 2010

Wrong Hand, Wrong Site Surgery--And The RIGHT Way To Handle This Medical Error

Unfortunately, wrong site surgery is more common than we would like to believe. Approximately two years ago, surgeon David Ring operated on the wrong hand of a patient. Apparently, for reasons unexplained in the article, Dr. Ring recently went public with this medical mistake. Why is this so newsworthy now? Sadly,

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.

How pervasive is the vexing problem of wrong site surgery?

In 2008, the most recent year with complete records, 116 wrong-site surgeries, up from 93 in 2007, were recorded by the Joint Commission, a national hospital accrediting agency. Preliminary reports logged 137 wrong-site surgeries from March 2009 through June 2010. That’s despite more than a decade of attention to the issue following the landmark 1999 Institute of Medicine report titled “To Err is Human.”

Dr. Ring is praised in the article for bringing this medical mistake to light, as he should be. This is the way totally preventable medical mistakes should be handled--with transparency. But I would disagree with any assertion that his going public with what happened is considered some sort of act of courage.

Admitting an obvious and indefensible medical mistake is not courageous; it is, simply, the right thing to do. As to the medical profession it may be considered courageous, but only because mistakes like this are often explained away, mitigated, or even justified as "system errors" or other euphamistic nonsense. A medical culture that discourages admitting error is the true root cause for the lack of coming forward and the transparency and honesty showed by Dr. Ring in this instance.

So give him a lot of credit for doing the right thing here. But the publicity this incident has garnered, and labelling it as an act of courage, says more about the current culture of the medical profession than anything else.

Bottom line: if a doctor makes a preventable medical mistake, just admit it and move on. That's why doctors and hospitals have malpractice insurance. When we get to the point that something like this is NOT newsworthy, the medical profession will have caught up to the rest of how society views personal responsibility and accountability.


Anonymous said...

The linked article was updated since this blog post was made. It wasn't a wrong site surgery, but instead a wrong procedure. These local TV station news sites are notoriously weak. I wonder if the doctor's own article published in the New England Journal of Medicine might reveal more of his intent in writing it. I doubt that he is holding himself out as a brave hero.

Brian said...

Thanks for clarifying this. I did not mean to imply that the Dr. is holding himself out as some sort of hero. He obviously is a stand up guy and is to be admired for his honesty. I only meant to state, perhaps incoherently, that the medical profession should not consider this as some sort of heroic act...