Health Care on MSNBC.com reports about a recent article in the New England Journal of Medicine about a surgeon's operating room error in Boston. What makes the article unusual is that it was written by the doctor who made the mistake.
Dr. David Ring from MGH presents a clear and understandable summary of the case, what went wrong, how he handled the disclosure to the patient, and many other important details.
He says, “Just imagine the worst thing that’s ever happened to you and that’s how it feels. I don't want anybody to make the same mistake I made."
In writing this article, Dr. Ring follows in the footsteps of Dr. Ernest Amory Codman, an MGH doctor from decades ago: "Dr. Codman made public the end results of his own hospital in a privately published book, A Study in Hospital Efficiency. Of the 337 patients discharged between 1911 and 1916, Dr. Codman recorded and published 123 errors."
Congratulations to Dr. Ring and to MGH for taking this step. As we have found in our own case, wide disclosure of such errors is the best way to learn from them and help avoid them in the future. It also sends a clear message to other clinicians that reporting of errors will be handled in a just manner.
Addendum to my original post (now edited), with still more thanks to Dr. Ring:
As another interesting twist to this, the first web article about this was a case of "wrong-site journalism" which unfortunately I got caught up in as well. The first article implied that this was a wrong side surgery. But it was the wrong surgery on the correct side, not wrong side surgery. The MSNBC.com piece has a disclosure of the error on the top of the page now. Oddly enough, I wrote my original post with the wrong interpretation -- even though I read the NEJM article. Apparently I got trapped by my own bit of cognitive anchoring by reading the earlier MSNBC.com article! As Dr. Ring says in a note to me: "To err is clearly human, which only helps emphasize the points that we all believe are so important to make."
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