A recent retrospective study of 42 Ophthalmic Mutual Insurance Company (OMIC) claims and 64 New York state cases by John W. Simon, MD, et al, published in the Archives of Ophthalmology, found that relative to other specialties, ophthalmologists commit fewer errors. The incidence was about 69 per million cases. Still, "the consequences of these kinds of errors are devastating," Dr. Simon said.
His goal was to investigate the consequences and contributing factors of surgical confusions and to assess how effective the universal protocol could have been in preventing them.
In a review of 42 closed cases from OMIC and 64 cases reported to the New York State Department of Health under its mandatory reporting system, Dr. Simon found:
- Wrong lens implant accounted for 67 of the 106 cases. (Five percent of OMIC reports related to wrong site/wrong IOL.)
- Seventeen wrong lens implants were due to problems upstream from the operating room, for example, transmission of a wrong lens order.
- Forty-six of the wrong lens implants were due to failure to check lens specifications and labels. In some cases training of personnel, lens storage and a change in OR schedules were to blame.
- Fifteen cases of wrong eye surgery were due to inadequate site verification. Most surgeries were halted, but two YAG capsulotomies and one corneal transplant proceeded.
In wrong eye cases, the surgeon was more likely to be the responsible party, said Dr. Simon. But in wrong implant cases, ancillary staff were more likely responsible, and the errors were less likely to be preventable and injuries more likely to be severe.
One recurring theme, he said, was that patients were often complicit in the errors. He attributed that to confusion. "They come in and they say, ‘This is the eye.'" After the surgery they recant. While he acknowledged that the correct surgical site should be in the chart, he said, "It should be, but sometimes not all of the different documents agree."
While he said he found the severity of injury in most cases were trivial or involved a return to the OR, some, like the two wrong corneal implants or the eight cases involving the wrong patient or wrong procedure, were more serious. Dr. Simon said, "If you've perpetrated an error, treat the patient and make a full, prompt honest disclosure, and you'll decrease your liability."
The American Academy of Ophthalmology, with the assistance of the American Board of Ophthalmology (ABO) and the Ophthalmic Mutual Insurance Company (OMIC), has established a Performance Improvement Taskforce. One of the goals of the taskforce is to identify areas of physician practice that can be improved through the consistent use of easy-to-implement, evidenced-based, and common-sense protocols. Wrong eye and wrong IOL implant surgery were chosen as the taskforce's first missions.
You can read the recommendations of the Wrong-Site Task Force here.
The taskforce is also developing an online CME activity that physicians can use to minimize wrong site surgery and wrong IOL implant. It should be available in February 2009. The resulting tool will allow physicians to:
- Compare their own practices to those based on protocols that are proven to reduce error and follow evidenced-based performance measures; and
- Easily adopt the system in their own office by providing them with simple to use checklists
In addition, the taskforce will collect anonymous data on the current and post-education practice activities to evaluate the changes in practice and outcomes as a result of the practice improvement activity.