For this well known Massachusetts’s General and Harvard Medical School hand surgeon, YES. Admitting publicly should ultimately improve patient care according to Dr. David C. Ring. Or his “public admission” will all be in vain.
Dr. David C. Ring, a well known hand surgeon and his colleagues at Massachusetts General Hospital, described in detail (New England Journal of Medicine) how a series of personal and system-wide mistakes led Dr. Ring to operate incorrectly on the hand of a 65-year-old woman with a painful “trigger finger.” Dr. Ring performed a carpal tunnel release, instead of a trigger finger release, a surgical error that would qualify as a wrong site and consequentially wrong surgery performed on the ” right ” patient. Realizing he made a surgical error fifteen minutes after the procedure, Dr. Ring apologized to the patient and her family then asked the consent of the patient to perform the correct procedure. When the patient consented, Dr. Ring reassembled his OR team and did the procedure without complications.
Dr. Ring and his medical staff went through the process of immediately rectifying the error post operatively. But nothing could “undo” this mistake, according to Dr. Ring himself. Though such case didn’t resulted to litigation and malpractice suit for the surgeon, such error put significant stress on both the patient and the surgeon. He just hope that with his public admittance of this error, other surgeons would improve on their patient safety protocols.
My first reaction reading this article was a unbelieving “really?”. In academic and training institutions for physicians, mortality and morbidity conferences are regularly conducted to improve patient care services and furtherance of the medical knowledge. But typically, they are for and amongst physicians only. Such hospital process analysis is guarded by the cloak of confidentiality, if only to protect the patient first and foremost. The fact is nowadays, going public with such ‘admission’ is a mortal sin, tantamount to inviting a deluge of malpractice suits for both the physician and the institution.
Thats why I am truly amazed by the act of Dr. Ring and his institution. The courage and integrity by which they face this situation is only paralleled by their unwavering desire to be at the forefront providing and improving the best of care for their patients. Such is characteristic of institutions of higher learning.
Now as to whether we are ready for such sentinel public admission, I personally don’t think so. Even if malpractice suits are still uncommon in our health care system, a turnaround in terms of our healthcare education, knowledge, attitude and skills should be effected first before we reach the social and psychological maturity of our caucasian counterparts. But this one should be an ideal goal. It might be utopian, but yes, it is still worth emulating.
So, Dr. Ring, all I can say is “bravo!”. You made us all orthopedic surgeons proud of our profession.