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J U N E 2 0 1 4 | O R E X C E L L E N C E. C O M S U P P L E M E N T T O O U T P AT I E N T S U R G E R Y M A G A Z I N E O N L I N E
T
he 65-year-old woman came to the day
surgery unit at Massachusetts General
Hospital in Boston for an elective trig-
ger-finger release. It was a procedure
orthopedic surgeon David Ring, MD,
PhD, had performed hundreds of times. What could
go wrong? Plenty, it turns out. In "The Worst Error of
My Career," orthopedic surgeon Dr. Ring will discuss
exactly why he performed a carpal tunnel release
instead. As he told us, the lessons are in the telling.
• Stress levels were high. It was the end of a
busy day, and she was my last patient — one of 3
hand cases scheduled after larger procedures.
Mentally, I had prepared to perform the more com-
plex cases followed by carpal tunnels. The surgical
schedule was backed up and one of my previous
patients who'd been nervous about receiving local
anesthesia needed additional comforting in recovery.
Stress levels were high and the case in question was
moved to another OR. The nurse who completed the
pre-op assessment did not follow the patient to the
new room.
• The moment he knew. I realized my error
about 15 minutes after the surgery, and immediately
informed the patient. She consented to having me
A bou t M y E r r or
An orthopod talks candidly about wrong-site surgery
David Ring, MD, PhD
Speaker Profile
• Presented his
error as a case
conference that
was eventually
published in the
New England
Journal of
Medicine.
• After the publica-
tion, he went on
the "wrong pro-
cedure world
tour."
• Associate profes-
sor of orthope-
dic surger y,
Har vard Medical
School.
where leaders meet, learn and grow together
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