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Ultrasound Cyclo Plasty in Eyes with Glaucoma
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Surgical confusions in ophthalmology.

John W Simon1, Yen Ngo, Samira Khan

  • 1Department of Ophthalmology, Lions Eye Institute, Albany Medical College, Albany, 1220 New Scotland Rd, Ste 202, Slingerlands, NY 12159, USA. simonj@mail.amc.edu

Archives of Ophthalmology (Chicago, Ill. : 1960)
|November 14, 2007
PubMed
Summary

Surgical confusions, primarily wrong lens implants, are rare but serious. The Universal Protocol could prevent 85% of these errors, highlighting the need for ophthalmologist involvement in prevention measures.

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Area of Science:

  • Ophthalmology
  • Medical Error Analysis
  • Patient Safety

Background:

  • Surgical confusions, though infrequent, carry significant consequences for patients, physicians, and the medical profession.
  • Public perception deems surgical errors unacceptable, necessitating robust prevention strategies.
  • Understanding the patterns and causes of surgical confusions is crucial for improving patient outcomes.

Purpose of the Study:

  • To test the hypothesis that surgical confusions are rare but unacceptable, occur predictably, and are often due to wrong lens implants.
  • To determine the preventability of surgical confusions using the Universal Protocol.
  • To analyze the circumstances, recognition, responsibility, and outcomes of surgical confusions.

Main Methods:

  • A retrospective analysis of 106 surgical confusion cases was conducted.
  • Data included cases from the Ophthalmic Mutual Insurance Company and the New York State Health Department.
  • Investigation focused on error occurrence, recognition, responsibility, patient notification, treatment, outcomes, and preventability.

Main Results:

  • Wrong lens implants constituted the most frequent error (63%).
  • Other confusions included wrong-eye operations (15%), wrong-eye block (14%), and wrong patient or procedure (8%).
  • The Universal Protocol could have prevented 85% of the analyzed confusions.

Conclusions:

  • Surgical confusions are infrequent but can have severe repercussions despite often causing minimal permanent injury.
  • Preventive measures, including the Universal Protocol, are essential for mitigating surgical errors.
  • Active participation and support from ophthalmologists are vital for implementing effective prevention strategies.