Wrong-Site Surgery in Pediatric Ophthalmology

Area of Science:

• Ophthalmology
• Surgical Safety
• Medical Error Analysis

Background:

• Wrong-site surgery (WSS) remains a critical issue in healthcare, despite established protocols.
• Pediatric ophthalmology, a specialized field, requires specific attention to surgical safety measures.

Purpose of the Study:

• To determine the prevalence of wrong-site surgery (WSS) among pediatric ophthalmologists.
• To identify risk factors associated with WSS in this specialty.
• To evaluate the effectiveness of the Universal Protocol in preventing WSS.

Main Methods:

• An anonymous 10-question survey was distributed to approximately 1,000 pediatric ophthalmology surgeons.
• Respondents were categorized into groups based on their experience with WSS.
• Risk factors including site marking, years in practice, and adherence to the Universal Protocol time-out were compared.

Main Results:

• Over 43% of the 156 respondents reported performing or attempting wrong-site surgery.
• Preoperative eye marking significantly reduced the likelihood of WSS (OR = 0.39).
• Experienced surgeons (in practice <15 years) had a lower likelihood of WSS (OR = 0.37), while years in practice and number of surgeries per year were not significant factors.

Conclusions:

• Self-reported wrong-site surgery is prevalent in pediatric ophthalmology, mirroring findings in other surgical fields.
• Key preventive measures include mandatory preoperative site marking and a structured Universal Protocol time-out led by a single individual with surgeon involvement.
• Surgeons with over 15 years of practice may benefit from additional safeguards to mitigate complacency and prevent errors.