Surgical Confusions in Ophthalmology

Abstract

To investigate the hypothesis that surgical confusions rarely occur but are unacceptable to the public; occur in predictable circumstances; involve a wrong lens implant more often than a wrong eye, procedure, or patient; and can be prevented using the Universal Protocol. Methods: A retrospective series of 106 cases, including 42 from the Ophthalmic Mutual Insurance Company and 64 from the New York State Health Department. We investigated how the error occurred; when and by whom it was recognized; who was responsible; whether the patient was informed; what treatment was given; what the outcome and liability was; what policy changes or sanctions resulted; and whether the error was preventable using the Universal Protocol. Results: The most common confusion was wrong lens implants, accounting for 67 cases (63%). Wrong-eye operations occurred in 15 cases, wrong-eye block in 14, wrong patient or procedure in 8, and wrong corneal transplant in 2. Use of the Universal Protocol would have prevented the confusion in 90 cases (85%). Conclusions: Surgical confusions occur infrequently. Although they usually cause little or no permanent injury, consequences for the patient, the physician, and the profession may be serious. Measures to prevent such confusions deserve the acceptance, support, and active participation of ophthalmologists.

The Cataract National Dataset electronic multicentre audit of 55 567 operations: when should IOLMaster biometric measurements be rechecked?

“…[2][3][4][5][6] As a result, accurate and precise measurements are a critical part of preoperative assessment and biometric errors are an important source of ophthalmic error. 7 To minimise such risk the United Kingdom (UK) Royal College of Ophthalmologists (RCOphth) Cataract Surgery Guidelines contain advice as to which outlying biometric measurements merit confirmation. 8 Stating that 96% of AL fall within the range 21.0-25.5 mm and that 98% K-readings lie between 40 and 48 D, the guidelines recommend measurements outside this range should be rechecked.…”

Use of the American Academy of Ophthalmology Surgical Checklist and Implant Timeouts: An Online Survey of Connecticut Ophthalmologists

“…Cataract surgery alone is the most commonly performed surgical procedure in the United States Medicare population, and is projected to increase in the future [4]. Second, there is ample evidence of surgical errors in ophthalmology, referred to by the literature variously as "surgical confusions", "never events", and "sentinel events" [5][6][7].…”

“…While incorrect implantation of intraocular lenses (IOL) accounts for the majority of these errors, incorrect operations, incorrect eye blocks, incorrect eye on which the operation is performed, and retained surgical items are all reported surgical errors in ophthalmology [5][6][7][8]. Most authors concur that a substantial number of these errors-up to 85% in one case series [5] -are preventable, given an appropriate system-wide intervention.…”

Safe eye surgery: non-technical aspects

“…7 Among surgical specialties, ophthalmology occupied the first place in surgical errors due to wrong intraocular lens implantation. 8 The second most common error in ophthalmic surgery is administering local anaesthetic to the wrong eye. Errors including operating in the wrong site/wrong patient/procedure are rare but unacceptable for the public.…”

“…Errors including operating in the wrong site/wrong patient/procedure are rare but unacceptable for the public. 8 The medical profession increasingly recognises that there is more to good surgical Recognition of the importance of these non-technical skills in anaesthesia has led to the development of aviation-style crew resource management training courses to address them, 5 for example, Crisis Avoidance and Resource Management, 2 and Anaesthesia Crisis Resource Management. 9 A taxonomy of anaesthetists' non-technical skills and a behavioural scale to rate them are now being used in some anaesthetic training programmes.…”