Patient Safety Tip of the Week


March 11, 2008

Lessons From Ophthalmology






John Simon and his colleagues at Albany Medical College have presented their retrospective review of 106 cases of surgical “confusions” in several venues (Simon 2007a, Simon 2007b, Simon 2007c). These include 42 cases from the Ophthalmic Mutual Insurance Co. and 64 cases from the New York Patient Occurrence and Reporting Tracking System (NYPORTS). 67 cases involved wrong lens implants, 15 cases wrong-eye operations, 14 cases wrong-eye block, 8 wrong patient or procedure, and 2 wrong corneal transplant. Based on these findings, they estimate an incidence of 6.9 such errors per 100,000 ophthalmologic surgeries.


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 Universal Protocol would have prevented the adverse event but most of the preoperative errors would not have been identified using Universal Protocol.


On the other hand, most of the 14 cases of anesthetic block to the wrong eye and 8 cases of wrong patient/procedure did result from inadequate verification procedures and could have been prevented by following Universal Protocol. While some of the contributory factors are those we have seen in other wrong site surgeries (eg. patients with similar names, site markings being obscured by skin pigmentation or covered by the OR cap or drapes, etc.), there were some factors somewhat unique to this patient population. Many (probably most) patients having cataract surgery have cataracts in both eyes. And in the elderly population the incidence of problems with cognition is more likely to result in patients misidentifying surgical site themselves.


For each type of event, the authors also examined the responsibilities, what as done for the patient, patient outcomes and severity, and liability payments. They give a good discussion of important steps to take, beginning in the office right on through the final verification process, to help prevent incidents of these types. They also have a good discussion about the importance of disclosure and apology to the patient.



Our June 5, 2007 Patient Safety Tip of the Week “Patient Safety in Ambulatoy Surgery” noted some other issues that may impact on cases done in the ambulatory setting. One factor is that a surgeon 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 lastly, the pressure to get cases done promptly and stay on schedule are everpresent.


The American Academy of Ophthalmology has issued good guidance statements on avoiding wrong-site surgery  and avoiding incorrect intraocular lens placement , with good examples of how checklists might be utilized. 






Simon JW. Preventing Surgical Confusions In Ophthalmology (presentation at NYSDOH Patient Safety Conference, Albany, NY, May 2007)




Simon JW. Preventing Surgical Confusions In Ophthalmology (An American Ophthalmolgical Society Thesis). Trans Am Ophthalmol Soc 2007;105:513-529



Simon JW, Ng Y, Khan S, Strogatz D. Surgical Confusions in Ophthalmology. Archives of Ophthalmology. 2007; 125(11):1515-1522









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