MD + nurse error = wrong-site surgery

A Boston surgeon publicly admits — and analyzes — his mistake in the November 11 issue of the New England Journal of Medicine. Dr. David C. Ring of Massachusetts General Hospital performed a carpal tunnel release, instead of a trigger finger release, on the left ring finger of a 65-year-old female patient. He realized his mistake while dictating the surgical report, immediately admitted the mistake to the patient and her family and, with the patient’s permission, performed the correct procedure.
The NEJM analysis reveals a multitude of errors and missteps — some of which involved nurses — that led to the mistake. Due to a last minute shift in venue, the nurse who performed the pre-op assessment was not in the operating room at the time of surgery. The patient, who was born in the Caribbean, only spoke Spanish; because an interpreter was not available, the physician, who spoke Spanish, communicated with the patient. A non-Spanish speaking OR nurse mistook a conversation between the patient and the surgeon for a pre-surgical timeout, so no formal timeout was observed before the operation. Poor placement of computer monitors also diverted nurses’ attention from the patient; to observe the monitors, the nurses needed to look away from the patient.

The NEJM article differentiates between active and latent errors, noting that the “most important” latent error was “a culture that allowed nurses who were not directly involved in the procedure to perform tasks such as marking the surgical site.” Since the incident, Massachusetts General has re-vamped their policies so that the surgeon marks the site with the agreement of the patient prior to anesthetizing the patient.

The article and public admission of error has drawn national attention. Do you think the surgeon’s admission will improve patient safety in the OR? Have you ever seen mistakes made due over-scheduling or short staffing?

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