Medical Errors and Surgical Confusion
By Lynda Seminara
Selected By: Stephen D. McLeod, MD
Journal Highlights
Ophthalmology, March 2020
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Parikh et al. evaluated medical errors in ophthalmic surgery as well as their incidence, root causes, and effects on patients and physicians. They found that episodes of surgical confusion often related to the use of incorrect IOLs in cataract surgery and that the most common cause of confusion was an inadequately performed or erroneous time-out assessment. Nearly two-thirds of errors were deemed preventable.
For this retrospective study, the researchers included 143 cases of ophthalmic surgical confusion identified during a 12-year period by the New York State Health Department or by closed-case files of the Ophthalmic Mutual Insurance Company. Main outcomes included error types, incidence rates, impact, causes, and preventability.
In two-thirds of the cases (95 of 143; 66.4%), the confusion involved implantation of the wrong IOL in cataract surgery. Thirty-three (34.7%) of these could not have been prevented by the Universal Protocol. Other errors were incorrect eye blocks or anesthesia (20 cases [14%]), wrong eye (10 cases [7%]), and inaccurate refractive surgery measurements (six cases [4.2%]).
The most common cause of confusion was an inadequately performed time out; this was responsible for nearly a third of the errors. The second most common cause—incorrect IOL order or calculation before surgery (“upstream” errors)—accounted for more than a fifth of cases. The average legal indemnity was greatest for incorrect medication ($284,000), followed by erroneous refractive surgery measurement ($123,125), wrong IOL choice ($57,514), and performing the wrong procedure ($50,000).
The authors noted that minor modifications of the Universal Protocol, particularly concerning upstream errors and poor communication during time outs, may help prevent future errors.
The original article can be found here.