One of the sad realities about many professions is how they find ways to hide the mistakes of their practitioners from the public. All too often, lawyers, doctors, and other professionals are not held accountable for even the most serious errors of judgment and practice.
That’s why this piece by Boston Globe healthcare blogger Elizabeth Cooney (link here) caught my eye:
In the same issue of the New England Journal of Medicine that contains a research article confirming the value of surgical checklists, a Boston surgeon tells his story of performing the wrong operation on a patient, one misstep at a time.
Cooney reports the story of “Dr. David Ring, a hand and arm surgeon at Massachusetts General Hospital,” who described in his report “a cascade of errors and omissions,” resulting in the doctor “performing the wrong operation on his patient’s finger.” Upon realizing his mistake soon after the surgery, Ring informed the patient, who allowed him to do the correct procedure. Later on, he took steps to alleviate the burden of the mistake on the patient.
Ring apparently decided to go public with his error to highlight the importance of using checklists and protocols to reduce the likelihood of patient errors associated with surgery. His Case Record in the New England Journal of Medicine can be accessed here. It provides an interesting look at how patient errors are reviewed by healthcare professionals.
I’m not suggesting that we celebrate Dr. Ring as being a hero for doing the right thing after a serious mistake, but I do think he deserves credit for his forthright actions and sense of personal accountability. For a variety of reasons ranging from impact on career prospects to risk of malpractice litigation, there exists an unfortunate and significant incentive for professionals to hide their mistakes, and too often the cultures of our professions buy into those sentiments. Thank goodness not everyone believes in practicing that way.
Minding the Workplace 
It’s very disturbing and disgusting to find an ER blame a community healthcare employee for the ER’s poor decision making, including neglectfully and dangerously discharging a patient to home when that patient desperately needed an inpatient admission!
I worked with some surgeons who before amputations of limbs would write, “Not this one”, with a sharpie on the good limb so no mistakes could be made during prep for surgery. There will always be errors when dealing with people, this is why the systems people work in are so important. Checks and double-checks followed religiously help prevent errors. In nursing hospitals often use incident reports as punitive, so many nurses do not report their errors. When incident reports are treated as learning tools errors get reported alerting everyone to take caution and change policies to prevent the same problem in the future.