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Ophthalmic surgical confusions preventable, study shows
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Although ophthalmic surgical confusions are rare and usually cause little or no permanent injury, such occurrences can largely be prevented, according to a study by researchers in New York.
John W. Simon, MD, and colleagues investigated the occurrence and circumstances of ophthalmic surgical confusions in a retrospective study of 106 cases, including 42 cases from the Ophthalmic Mutual Insurance Company and 64 cases from the New York State Department of Health.
Specifically, the investigators looked at "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," the study authors wrote.
The researchers found that the most common surgical confusion involved implanting the wrong lens, which occurred in 67 cases (63%).
Other surgical confusions included lenses implanted into the wrong eye in 15 cases, anesthesia injected into the wrong eye in 14 cases, performing the wrong procedure or operating on the wrong patient in eight cases and transplanting the wrong corneal graft in two cases, according to the study.
Use of the Universal Protocol, which was developed by the Joint Commission along with professional ophthalmic organizations, would have prevented the confusion in 90 of these cases (85%), the authors noted.
The Universal Protocol calls for "consistent preoperative verification, site marking and a time-out immediately before incision," they said.
"Measures to prevent such confusions deserve the acceptance, support and active participation of ophthalmologists," the authors said.
The study is published in the November issue of Archives of Ophthalmology.