The Surgeon's Account

Dr. David C. Ring: This 65-year-old woman with a trigger finger that did not respond to glucocorticoid injection elected operative treatment under local anesthesia. She was my last patient scheduled for surgery that day and was one of three patients who were having hand surgery under local anesthesia, following three other patients who were having larger procedures performed while they were under general or regional anesthesia. My mind-set at the start of the day was, “I have three big procedures that I have specifically planned and prepared for and a few 'carpal tunnels' to perform today.”

The first minor hand surgery was a carpal-tunnel release, with the patient under local anesthesia. The patient was quite nervous about the injection of the anesthetic agent. The surgery went well, but as we applied the dressing, she again became upset about the injection of the anesthetic, and I had to help console her.

Shortly thereafter and approximately 1 hour before the operation on the patient who is the subject of this conference, I was asked to translate during her preoperative preparation, since I speak Spanish and no interpreter was available. According to hospital protocol, the correct arm had been marked at the wrist by the nurse but the planned incision site on the hand was not marked. I went through my usual preprocedure routine with the patient, verifying the symptoms, the abnormal findings on physical examination, and the informed consent. I confirmed a persistent trigger finger of the left ring finger and reviewed the risks and benefits of the procedure with the patient.

Next I went to another operating room and performed a carpal-tunnel release on the second patient, without incident. Stress on the day-surgery unit was high because several other surgeons were behind schedule. The decision was made to move my last patient to another operating room. In addition to the change in venue, this resulted in a change in personnel; in particular, the nurse who had performed the preoperative assessment would not be in the room with us during the procedure.

The change of rooms also introduced a delay, during which I went to an inpatient floor for a consultation. When I returned to the outpatient-surgery area, I was told that the patient who had been upset about the injection of the anesthetic for her carpal-tunnel release had become very agitated in the recovery area. Although I was able to help put her at ease, the encounter was very emotional, producing in me both the cognitive and physiological aspects of anxiety, as well as a resolve to do everything possible to prevent such an unpleasant experience for future patients. Her emotions were very intense, and my sympathy for her was such that I recall privately counseling myself that the next operation would be “the best carpal tunnel release that I have ever performed.”

When I entered the room, the patient was already there and preparations were under way. I noticed that we did not have a tourniquet. The circulating nurse had to leave the room to get one, which distracted her from the patient and made her fall behind on her documentation. The patient's arm was washed with soap, alcohol, and povidone–iodine according to hospital protocol. The alcohol caused the site marking to be wiped off the limb. I spoke with the patient in Spanish, which the circulating nurse mistook as a time-out, and as a consequence, no formal time-out took place before the procedure was begun. In addition, there was a change in the nursing team in the middle of the procedure.

I performed a carpal-tunnel release on this patient, rather than a trigger-finger release. About 15 minutes later, while I was in my office dictating the report of the operation, I realized that I had performed the wrong procedure. I immediately informed the staff and then went straight to the patient and personally informed her of the error. I apologized and explained that I could perform the correct procedure if she wanted me to do so. She agreed, and I reassembled the staff. During the preparations for the correct procedure, I filed a safety report and notified the hospital's risk manager of the error and the rectification. I then performed a trigger-finger release, without complication. The patient was discharged home that day after a brief recovery.

I spoke with the patient's son by phone several times after the operation to apologize, waive fees, and arrange follow-up care. Several days after the incident, he informed me that his mother had lost faith in me and would not return. I received a call from a community clinic associated with our hospital where the patient went to have sutures removed, and I instructed them in the postoperative management. All charges were waived, according to Massachusetts General Hospital policy. A financial settlement was negotiated shortly after the event.