Study characterizes surgical confusions in ophthalmology

This study examined the origins of surgical errors and their prevention.

Study design

Researchers selected 143 cases of surgical error from 2006 to 2017; cases were analyzed and classified by error type to ascertain preventability by using the Universal Protocol.

Outcomes

Of the 143 cases studied, 92 were preventable via the use of the Universal Protocol. The most common surgical errors were incorrect intraocular lens implants (66.4%), followed by incorrect eye block/anesthesia (14.0%), and incorrect eye. However, half of the refractive surgery corrections were not preventable by the Universal Protocol because they occurred upstream, such as IOL lens calculation errors.

The most common root cause of confusion was an inadequately performed time out, which was responsible for nearly one third of all surgical confusions.

Limitations

Study limitations include a relatively small sample size and a lack of guidance on ways to prevent calculation lens choice errors. In addition, the study did not consider application of the ophthalmology-specific checklist from the Academy.

Clinical significance

Most surgical errors are preventable and surgeons should regularly review and implement the Universal Protocol. The leading root cause of surgical confusion was found to be an inadequately performed time out, followed by incorrect orders or intraocular calculations.

About a third of incorrect intraocular lens implantation could not have been prevented by Universal Protocol because these errors began upstream. Transcription errors, incorrect calculations of lens power from incorrect axial length, incorrect keratometry or incorrect lens formula were responsible for 44.8% of incorrect intraocular implants. The authors suggest surgeons use the primary source of clinical data, such as the original clinic note, and cross reference type of lens, refractive target and lens calculations to avoid confusions. Other suggestions include labeling implants and removal of extraneous lenses from the operating room.

In addition to those recommendations made in the paper, surgeons should adapt ophthalmology-specific surgical checklists and implement upstream systems to prevent errors. The Academy’s wrong-site-wrong-IOL checklist is specific to ophthalmology and addresses methods to prevent implant errors such as those described in the study.