Reducing wrong intraocular lens implants in cataract surgery

Abstract

Purpose Wrong lens implants have been associated with the highest frequency of medical errors in cataract surgery. The purpose of this paper is to explore the use of the Systems Engineering Initiative for Patient Safety (SEIPS) framework to sustainably reduce wrong intraocular lens (IOL) implants in cataract surgery. Design/methodology/approach In this mixed-methods study, the SEIPS framework was used to analyse a series of (near) misses of IOL implants in a national tertiary specialty hospital in Singapore. A series of interventions was developed and applied in the case hospital. Risk assessment audits were done before the interventions (2012; n=6,111 surgeries), during its implementation ( n=7,475) and in the two years post-interventions (2013-2015; n=39,390) to compare the wrong IOL-rates. Findings Although the absolute number of incidents was low, the incident rate decreased from 4.91 before to 2.54 per 10,000 cases after. Near miss IOL error decreased from 5.89 before to 3.55 per 1,000 cases after. The number of days between two IOL incidents increased from 35 to an initial peak of 385 before stabilizing on 56. The large variety of available IOL types and vendors was found as the main root cause of wrong implants that required reoperation. Practical implications The SEIPS framework seems to be helpful to assess components involved and develop sustainable quality and safety interventions that intervene at different levels of the system. Originality/value The SEIPS model is supportive to address differences between person and system root causes comprehensively and thereby foster quality and patient safety culture.

The Value of Learning From Near Misses to Improve Patient Safety: A Scoping Review

“…Eight articles defined or described near misses as situations where events had not reached the patients 30,32,33,35–39 . Ten articles defined or described near misses that included events that had reached patients 31,34,40–45 and could be considered to potentially cause harm 46,47 . Early et al 48 described learning from a “near-miss sentinel event,” but provided no further information about the event or its impact.…”

“…Where there was evaluation, articles commonly measured the occurrence of safety events as a metric for impact. Reductions were seen in unintended event rates, commonly the near misses themselves 30,33,35–41,43–47 . Loh et al, 47 for example, described a reduction in the number of intraocular lens events (near misses) from 5.89 before to 3.55 per 1000 cases.…”

Management of ophthalmic surgical instruments and processes optimization: mixed method study

“…In a literature review by researchers from England it is demonstrated that 1 out of each 20 surgical patients experienced an undesirable and avoidable event during care, a fact that reinforces the need to improve all processes involving surgical care (7) . With regard to ophthalmic surgeries, among the possible adverse events are visual deficiencies and loss of vision, to, making feasibal an environment with effective and stable communication is a way to minimize occurrences of errors, making surgical processes safer (8) . Thus, the importance of investing in planning and appropriate management of materials used in ophthalmic surgeries is considered.…”

A Digital Patient-Led Hospital Checklist for Enhancing Safety in Cataract Surgery: Qualitative Study (Preprint)

“…Studies show communication problems are root causes of wrong IOL implants in cataract surgery [26]. In New York State, wrong implant-related errors account for 63 percent of the total number of malpractice claims and data from Veterans Health…”