Preventing Surgical Confusions in Ophthalmology
Transcript of Preventing Surgical Confusions in Ophthalmology
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Preventing Surgical Confusions in Ophthalmology
John W. Simon MD
Professor and ChairmanDepartment of Ophthalmology
Albany Medical College
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Surgical Confusions
• Wrong patient• Wrong site• Wrong procedure• (Wrong implant)
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Incidence Unknown
Rarely reported except in lay pressPIAA: 1000 liability claims on fileVA: 1/25,000 = 1/month in USHand surgeons: 16% nearly, 21% didJCAHO: 58% ambulatory
Site 76%, Pt/procedure 24%
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Risk Factors
• Breakdown in communication• Inadequate verification of pt or procedure• Staffing, distraction, language• Emergent, multiple sx, pt characteristics• Busier, more experienced surgeons
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Why Ophthalmology?
Orthopedics, urology, neurosurgery• Incidence in ophthalmology unknown
Potentially devastating• Contributing factors ?• Consequences to pts, ophthalmologists?• Effectiveness of Universal Protocol?
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Hypothesis
• Confusions occur rarely• Unacceptable: public, legal, regulatory• Often predictable risk• Wrong IOL > eye, pt/procedure• Preventable w/ Universal Protocol
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Methods
42 closed cases (40%)OMIC, 1982-2003
64 NYPORTS (60%)NYSDOH, 2000-2005
Masked pts, institutions, surgeons
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Methods, cont’d
• What error, how occurred?• Who recognized, when?• When occurred, who responsible?• Was pt/family informed?• What treatment, severity?• Was it preventable w/ UP?• What liability, sanctions?
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67 (63%) Wrong Lens Implant17 errors preoperative
A-scan not programmedTranscription errors in officeUnlikely preventable with UP
46 errors intra-operativeFailure to check lens spec’s Labels, training, storage
R/L, powers, schedulesWorkload, distraction
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15 (14%) Wrong Eye
Inadequate site verificationDrape covered mark, tape moved• 5 lacrimal drainage surgeries• 3 cataract procedures: 2 halted• 2 YAG capsulotomies• 1 retinal detachment: halted• 1 lid procedure: halted• 1 corneal transplant
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14 (13%) Wrong Eye Blocks
Inadequate site verification• Site marking, time-out not done• Purple mark on pigmented skin• Some errors made in officePatient confusion, complicity
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8 (8%) Wrong Patient/Procedure
Inadequate patient identification• Clinic laser procedures• Two similar namesExotropia repair for pt w/ esotropia
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2 (2%) Wrong Transplant
Corneal transplants• Incorrect tissue in refrigerator• Inadequate verification
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Who and When Recognized
Surgeon 66 (65%)• OR staff 19• Patient 4 (wrong eye/block)
At facility 80 (75%)• In OR 23Recovery period 23 (22%)
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Statistical Analysis
Wrong eye/pt/procedure• 64% surgeon alone responsible• 97% preventable
Wrong implant/transplant• 81% others partly responsible (p=.001) • 77% errors preventable (p=.009)• Injuries more severe (p=.001)
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Was Pt/family Informed?
YESNOUnknown
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Injury Scores
1: Temporary/insignificant– Scar only
2: Temporary/minor– Delayed recovery, return to OR– < 3 D over- /under-correction
3: Mild/permanent– Longer delay, > 3 D
4: Severe permanent injury– Permanent loss of vision
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Severity of Injury Score
1234
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Policy Changes and Sanctions
Policies strengthened: 56/64 Practice monitored: 5/64 Temporary suspension: 1/64
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Incidence in Ophthalmology
62 cases/900,000 eye surgeries• 6.9/100,000 = 69 sigma• Manufacturing standard = 6 sigma• Under-reporting?
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Liability
42 / 2256 closed cases• 1.86% of liability concerns• Payment in 48% vs. 21% overall• Suits basically indefensible
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Ophthalmology Like Other Specialties
Switched schedules, personnelCommunicationPre-op verification, site marking, time out• Must take seriously• Checklist: simplifies• Watch drape, color, tape
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Ophthalmology vs. Other Specialties
Wrong site, pt/procedure rareWrong implant common: 64%• 70% of wrong equipment cases• IOLs look alike and pts can’t help
16/106 cases likely unpreventable w/ UP• Need vigilance throughout process• Need special care with implants
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Most Errors Mild, Treatable
• Wrong implants replaced– Corneal surgery, piggyback options
• Wrong blocks dissipated• Laser refractive surgery re-treatable• Glaucoma, lacrimal procedures harmless• Strabismus surgery re-doneAverage indemnity $30 K vs. $91 K overall
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14 Cases Severe (3 or 4)
• New glaucoma, corneal decompensation• Corneal transplantation only good eye• Severe refractive error one or both eyes• Annoying diplopia, asthenopia common
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Procedures Deserve Support
SanctionsLiabilityEmbarrassmentConscienceReputation: individual
profession
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Enlightened Approach
If error: treat patientPrompt, full, honest disclosure• Acknowledge harm• Take responsibility• Explain what happened• Show remorse• Make amends: won’t recur
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Enlightened Approach, cont’d
“Blame, Shame, Train”• Encourages culture of secrecy• Inhibits effective RCA, improvementCaregiver as the “second victim”• Humans make mistakes• Crew resource management
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Improving Patient Safety
• Oversight organizations• Professional groups• Group purchasers• Standards for information• Safety systems at delivery level• Culture of safety