Patient Safety and Risk Management in an Accumulation of Postoperative Endophthalmitis Cases after Vitrectomy in a...

To describe the risk management at a university eye hospital after two outbreaks of nosocomial endophthalmitis cases after pars plana vitrectomy.

In two series of postoperative endophthalmitis cases after in-house vitrectomy, the basic workflows in direct patient care were evaluated with regard to patient safety. Hygienic microbiological environmental examinations were performed on relevant materials and surfaces. In particular, the direct surgical utensils were inspected with regard to possible bacterial colonisation.

Pathogens (Staphylococcus aureus) were detected in 2 of 7 endophthalmitis cases. The S. aureus strains showed no clonality. The procedures were 23 G and 25 G vitrectomies for retinal detachment (3× rhegmatogenous, 1× PVR), subretinal macular hemorrhage (1×) and vitreous haemorrhage for proliferative retinopathy (2×). The duration of surgery was between 20 min and 65 min; the time between initial vitrectomy and the surgery for endophthalmitis was between 2 and 5 days (mean 3.6 days). A silicone oil filling was instilled once during the first operation and otherwise the eye was tamponaded with gas (4×) or air (2×). The surgical teams were heterogeneous; n = 5 surgeons were involved and the initial procedures took place in n = 4 different operating theatres. In all cases, general anaesthesia was applied (6× laryngeal mask, 1× endotracheal intubation). No definitive source of infection was found. The interventions with regard to patient safety were therefore aimed at strengthening compliance with existing measures for preventing infection and adapting work processes. In the acute phase, antibiotics were instilled intraoperatively into the anterior chamber after vitrectomy, contrary to the usual in-house procedure. Other types of intraocular surgery were not affected.

The accumulation of in-house endophthalmitis cases is a catastrophic event in an eye clinic and stringent risk management is required to identify the causes. Openness and transparency are essential factors for an adequate workup. This manuscript shows what the individual steps could look like and how the results can be dealt with. The problem of not having found a clear point source for the infections is discussed.