Ophthalmic surgical errors infrequent but serious when they do happen

Ophthalmic surgical errors infrequent but serious when they do happen

Surgical errors, such as operating on the wrong site, the wrong patient or the wrong procedure do not happen often in ophthalmic procedures, according to an article in Archives of Ophthalmology (JAMA/Archives), November issue. These mistakes ("confusions") do not usually lead to permanent injury - however, they may involve serious consequences for both the patient and the physician. The authors explain that these confusions could often be prevented.

The researchers write "Surgical confusions are an increasingly recognized cause of morbidity, recently representing the most common category of reportable medical error. In July 2004, the Joint Commission on Accreditation of Healthcare Organizations, in concert with many professional organizations, including the American Academy of Ophthalmology, promulgated the Universal Protocol in an effort to prevent such confusions in all surgical procedures. This protocol includes consistent preoperative verification, site marking and a time-out immediately before incision."

John W. Simon, M.D., of the Lions Eye Institute, Albany Medical College, N.Y., and team looked at 106 cases of surgical confusions involving ophthalmic procedures that took place between 1982 and 2005. 42 of them were from the Ophthalmic Mutual Insurance Company and 64 from the New York State Health Department.

The researchers found that:

-- There were 67 wrong lens implant confusions, 63% of all cases. They mainly occurred because the lens specifications were not checked properly beforehand.

-- There were 14 cases (13%) of anesthesia being injected into the wrong eye

-- There were 15 cases of the wrong eye being operated on (this overlaps with the previous one)

-- There were 8 cases of the wrong patient getting the procedure (or the wrong procedure being performed on a patient)

-- There were two cases of the wrong tissue being transplanted

The confusions that caused the most severe injuries were those involving the wrong implant or transplant, as opposed to those involving the wrong eye, procedure or patient, the researchers report.

85% of those confusions would not have happened if the Universal Protocol had been implemented.

The researchers worked out that the confusion rate in the USA is 69 per 1 million eye operations.

The authors write "The causes of these confusions were faulty systems, processes and conditions that led people to make mistakes, more often than an individual's recklessness. The traditional response to medical error, 'blame, shame and train,' therefore misses the point. Humiliating or otherwise disciplining caregivers tends to perpetuate a culture of secrecy that impedes effective root-cause analysis and future improvement. A more enlightened approach is entirely non-punitive, drawing on methods of crew resource management adapted from the airlines and the defense department."

"Surgical Confusions in Ophthalmology"

John W. Simon, MD; Yen Ngo, MD; Samira Khan, MD; David Strogatz, PhD

Arch Ophthalmol. 2007;125(11):1515-1522.

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