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Extra steps help avoid implantation of wrong IOL


Issue: October 10, 2012

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In the United States, approximately 20.5 million people aged 40 and older have cataracts, and more than 1 million cataract surgeries are performed annually. Less than 5% result in complications, according to Prevent Blindness America. 


Complications that result from human error, however, are not easy to document. According to Oliver D. Schein, MD, and colleagues, differences in case definition, ascertainment and time surveyed make it difficult to record an accurate rate of wrong IOL implantations in cataract surgeries.


“However, if the rate of wrong IOL due to error in selection were on the order of 1 per 10,000, this would yield approximately 200 such cases annually in the United States,” the study authors said in Ophthalmology.


“Safety in surgery involving IOLs is enhanced both by strict procedures, such as an IOL-specific ‘time-out,’ and the fostering of a surgical team culture in which all members are encouraged to voice questions and concerns,” they said.


According to Schein, it is beneficial for operating room staff to work together before, during and after procedures.


“It is insufficient for the surgeon alone to be vigilant,” he said in an interview. “The surgeon has many potential distractions. A team approach is needed.”


The retrospective case series reviewed six surgeries in which the wrong IOL was implanted because of human error and one “near-miss” case. The mistakes involved miscommunication between surgeons and staff and incorrect patient or IOL information.


Recommendations


Schein offered several tips to ensure wrong IOL implantation does not occur:


• Identify all key steps, which begins with the measurements.

• Minimize or eliminate transcribing.

• Work with the operating room facility to ensure there is a routine for checking the IOL and patient information before the incision is made.

• Ensure that double-checking is done not only by the surgeon, but also by a nurse or technician.

• Use two or more patient identifiers, such as full name and date of birth or medical record number, to confirm that the IOL calculation sheet for a given patient matches the consent form.


It is commonly accepted that most opportunities to prevent wrong IOL implantation occur in the operating room. Ironically, Schein said, the growing potential to use technology to reduce errors may also introduce errors. 


“Such technology is also likely to be imperfect, since an error once made in an electronic system is often propagated downstream,” Schein said.


Effects of wrong implantation


Repeated cases of wrong IOL implantation prompted the Joint Commission on Accreditation of Healthcare Organizations to create a universal protocol to establish a consistent approach to preventing surgical errors. The American Academy of Ophthalmology also created a wrong-site task force to help surgeons and staff avoid preventable errors.


“The risk of implanting the wrong IOL as the result of human or system error has decreased over recent years,” the study authors said. “The AAO’s 2008 operative checklist was a major milestone in this evolution.”


Schein said implanting the wrong IOL could significantly hurt a clinician’s reputation. He said financial and social expenses are minimal when compared with the loss of trust in the physician, the potential for complications from additional surgery and the potential for regulatory intervention.


“Hopefully this study will draw attention to such errors and the importance of a systematic and team-based approach to preventing them,” he said. – by Ashley Biro