A 58-year-old women developed pain at the base of her right thumb and saw a primary care physician who referred her to physical therapy. After no improvement, she was referred to an orthopedist who diagnosed her as having DeQuervain’s tendonitis in her right thumb. Cortisone shots and further physical therapy provided no pain relief, so surgery was recommended. During a preoperative office visit, the doctor realized the surgery had been mis-scheduled as a carpal tunnel release in her wrist instead of DeQuervain’s surgery. He corrected the surgical scheduling, but at the time of the actual surgery, the change still wasn’t made on the hospital operating room schedule. The doctor “forgot” that he was to perform the surgery for DeQuervain’s tendonitis instead of a carpal tunnel release, and proceeded to operate on the woman’s wrist rather than her thumb. The woman has been undergoing intensive physical therapy, and remains in considerable pain.