The UK National Patient Safety Agency (NPSA) has posted the new Surgical Safety Checklist: for Cataract Surgery ONLY, based upon the WHO Surgical Safety Checklist.
Cataract surgery has a special place in our patient safety journey. Our initial interest in surgical timeouts and checklists stemmed from a root cause analysis on an ophthalmology incident. That incident led to the development of one of the first formal surgical timeout policies, which later became a model for New York State’s first foray into surgical timeout policies (see the New York State Surgcal and Invasive Procedure Protocol (NYSSIPP). Also, during a lull at one of the meetings of the statewide NYPORTS (New York Patient Occurrence and Report Tracking System) committee we asked attendees if they had ever seen implantation of incorrect lenses during cataract surgery. One hand after another shot up! Probably a third of attendees had experienced this at their hospital. John Simon and his colleagues at Albany Medical College subsequently analyzed all such cases in the NYPORTS database and an ophthalmology malpractice claims database. His work and the references are summarized in our March 11, 2008 Patient Safety Tip of the Week “Lessons from Ophthalmology”.
Implantation of the wrong intraocular lens was the most common occurrence in both databases. Errors in both the preoperative period and operative period were found to lead to the incorrect implantation. In the preoperative period, contributory causes identified included faulty calibration of the A-scan equipment, transposition of records from the ophthalmologist’s office, transcription errors, switched patient identification stickers, and transposition of IOL power calculations while faxing records on two patients at the same time.
Intraoperative errors in almost all cases involved failure to identify the lens specifications properly before implantation. Multiple contributory factors were indentified, including changes in the OR schedule, changed staff assignments, staff changes during the procedure, poor lighting, multitasking and other distractions, and misreading the label on the implant box. In one case the surgeon had dropped multiple patient charts and they were out of order when reassembled. (Note in our June 5, 2007 Patient Safety Tip of the Week “Patient Safety in Ambulatoy Surgery” we discourage the practice of allowing the medical records of multiple patients to be in the operating room since it is too easy to mistakenly pick up the chart of the wrong patient during a procedure.) In 77% of the cases with adequate information the authors felt that adherence to would have prevented the adverse event but most of the preoperative errors would not have been identified using Universal Protocol.
The new Surgical Safety Checklist: for Cataract Surgery ONLY is based upon the WHO Surgical Safety Checklist. Our July 1, 2008 Patient Safety Tip of the Week “WHO’s New Surgical Safety Checklist” described the original tool and provided the link to download the checklist tool and instructions how to use it. We also discussed checklist design and use in our September 23, 2008 Patient Safety Tip of the Week “Checklists and Wrong Site Surgery”.
Like the prototype WHO Surgical Safety Checklist, there are 3 phases in the cataract checklist: sign in, timeout, and sign out.
The sign in phase (done before any anesthetic is administered) includes identification of the patient and the procedure to be performed and the consent for that procedure. It also includes whether site marking has been performed and a precheck of any anesthesiology equipment and whether VTE prophylaxis is indicated. It includes some questions important for anesthesiology (allergies, airway accessibility, special needs for draping or positioning). It then asks some questions important to the ophthalmologist: Is the Patient on warfarin? Is the patient on tamsulosin or other alpha blocker? The first question obviously raises the question of bleeding risk and the latter the risk of the “intraoperative floppy iris syndrome (IFIS)” and other complications (Bell et al 2009).
During the timeout phase, the team introduces itself and confirms the patient identification, the procedure to be performed, the correct eye, the intended refractive outcome, the power and model of the lens to be implanted, and whether that lens implant is physically present. Then any anticipated variations or critical events are discussed. For instance, the surgeon may discuss and planned variations in the surgery, need for special equipment, alternative lenses, etc. The anesthesiologist notes the ASA class, status of monitoring equipment, and any patient-specific problems. The scrub nurse notes whether sterility of the instruments has been confirmed and notes any other equipment issues.
The sign out phase included documentation of the name and side of the procedure, status and count of all instruments, swabs and other materials, identification of any equipment issues, and instructions for post-procedural care of the patient.
This checklist could be further modified at your individual sites.
Some other issues in our June 5, 2007 Patient Safety Tip of the Week “Patient Safety in Ambulatoy Surgery” are worth repeating. One factor is that a surgeon in ambulatory surgery will often be performing many cases of the same or similar procedures. Interestingly, very experienced surgeons may be more likely to be involved in wrong-site cases, perhaps because their experience allows them to schedule so many cases in one day. The quality of the medical records is often not as good in ambulatory settings. The “facility” medical record is often scant and the physician often brings in his/her office notes that are “unofficial” as far as the facility is concerned. Often critical information is in the physician office record and never appears in the facility medical record. It is therefore incumbent upon the facility and entire team to ensure the adequacy of the medical record and all documentation prior to the procedure. And there are certain production pressures unique to the ambulatory setting. When a surgeon is booked for many cases in one day, there is a higher likelihood of last-minute changes in the schedule. Also, we’ve seen cases in the ambulatory setting where one patient may demand a procedure earlier in the day, leading to last-minute alterations in the order on the schedule. And the pressure to get cases done promptly and stay on schedule are everpresent. Lastly, don’t allow the medical records of multiple patients to be in the operating room at the same time since it is too easy to mistakenly pick up the chart of the wrong patient during a procedure.
The recommendations of the American Academy of Ophthalmology Wrong-Site Task Force are also quite valuable and include special attention to intraocular lens implants and a checklist to help. One good recommendation there is that the circulating nurse writes on the white board the patient’s name, operative eye, IOL style, and IOL power.
NHS NPSA. Surgical Safety Checklist: for Cataract Surgery ONLY
(adapted from the WHO Surgical Safety Checklist)
WHO Surgical Safety Cheklist
WHO Safe Surgery Saves Lives website (includes also an implementation manual and videos on how to use the checklist and how not to use it)
Chaim M. Bell CM, Hatch WV, Fischer HD et al. Association Between Tamsulosin and Serious Ophthalmic Adverse Events in Older Men Following Cataract Surgery.
JAMA. 2009; 301(19): 1991-1996
American Academy of Ophthalmology. Recommendations of the American Academy of Ophthalmology Wrong-Site Task Force. November 2008.