As soon as Dr. David Ring realized he performed the wrong surgical procedure on a patient, he decided he would be open and upfront about the incident.
David Ring, MD, was in the peak of his career when he accidentally performed the wrong surgery on a patient.
It was a hectic morning in 2008. Ring was working as a hand and arm surgeon at Massachusetts General Hospital, and he had six surgeries that day — three intensive surgeries in the morning and three simple procedures in the afternoon.
Difficulties compounded: a patient becoming anxious after receiving anesthesia, a shift change between surgeries, a change of rooms at the last minute, no formal break.
Ring referred to it as “the Swiss cheese model of errors.”
“While there were many layers of cheese that day — many people that could have caught my error — the holes all lined up,” he says.
Ring completed a procedure for carpal tunnel on a patient who had a condition known as “trigger finger.” Without realizing his mistake, he returned to his office to fill out paperwork. Then it hit him.
“It’s really hard to describe the feeling,” Ring says. “It was like the ground fell. Like there was nothing to stand on. There’s a split second where you can imagine it’s a bad dream or it didn’t happen, or you can imagine a way for it to not be true. Then you realize that’s ridiculous and that you’ve done the wrong thing.”
As soon as Ring realized his mistake, he decided he would be open and upfront about the incident. He apologized to the patient and performed the correct surgery, filed the appropriate paperwork and, within one week, was in a public forum, openly speaking about it.
“People really suffer when they can’t talk about it,” he says. “I can’t even imagine what would have happened if I couldn’t talk about it.”
Dwight Burney, MD, works in nontechnical skills and patient safety training with the Academy of Orthopedic Surgeons in New Mexico. Burney remembers being counseled by attorneys to sever ties with unhappy patients when he first entered into practice decades ago as an orthopedic surgeon.
“I think David’s response was really the right thing to do and that sort of thing was sort of counterintuitive years ago,” Burney says. “We know that that kind of thinking has led to a number of suicides of health care providers who have been associated with a catastrophic patient harm.”
Burney says silence and shame aren’t acceptable responses. Instead, health care leadership should understand that making mistakes is normal, and that health care providers are human.
“When the expectation is that you will not make errors, what happens when you do make errors is that you don’t disclose them,” Burney says. “And so nobody learns anything.”
Since Ring has gone public with his story — he even described the incident in the New England Journal of Medicine — he has had many medical professionals come to him with their own mistakes.
“When you give a story, you get a story,” he says. “Whether in print or in public, people would come up to me and tell me a story. They need to talk about it, and they felt comfortable with me because I was talking about it.”
Instead of drowning in feelings of inadequacy after a mistake has been made, Ring believes it is much more constructive to have a “growth mindset,” where you move forward by learning from your mistakes. He believes other health care professionals can learn from his own story as well.
“There’s no doubt that people can learn from it, and if the first thing they learn is that doctors are human, that’s a good start,” he says.
Hannah O. Brown is a freelance health care writer based in Florida.