November 2016




Report offers recommendations for handling adverse events in cataract surgery

by Ellen Stodola EyeWorld Senior Staff Writer

Betsy Lehman Center logo
This was sparked by an increase in reports of adverse event associated with cataract surgery.

Source: Betsy Lehman Center for Patient Safety

A report by the Betsy Lehman Center includes recommendations from an expert panel looking at a number of adverse events

Complications during surgery are a major concern, especially if they are avoidable. An increase in Massachusetts from 2014–15 in reports of adverse events during cataract surgery prompted an advisory and then creation of an expert panel to examine these serious reportable events and provide recommendations on how they could be prevented in the future. Adverse events included implantation of the wrong IOL, surgery performed on the wrong eye, surgery performed on the wrong patient, and mistakes in the administration of anesthesia, which in some cases resulted in permanent loss of vision. A report of the panel’s findings was released earlier this year by the Betsy Lehman Center for Patient Safety, a Massachusetts state agency. Work on the report started in spring 2015, and was triggered by an uptick in the number of adverse event reports associated with cataract surgery, said Barbara Fain, executive director, Betsy Lehman Center for Patient Safety, Boston. In Massachusetts, there is a mandatory reporting system for medical errors. “The challenge of a high volume procedure such as cataract surgery is that people develop a false sense of security by doing the same thing over and over with good results,” Ms. Fain said. The understandable assumption is that nothing is wrong with the systems.

After receiving this indication that adverse events were occurring, the Betsy Lehman Center interviewed staff at various facilities that had reported the errors. The common thread in the conversations, Ms. Fain said, was the belief that these kinds of mistakes could never happen at their own facilities. So the message that the report is trying to convey is not about blaming providers or individuals, but rather drawing attention to the fact that these events can happen anywhere and are oftentimes not reported. There are many places in the system where seemingly minor breakdowns could happen, she said. If they’re not caught, they could result in the patient being harmed.

“Our goal here was to identify the risks,” Ms. Fain said. Another goal was to alert the cataract surgery community to the fact that these kinds of events are happening.

The report makes a series of recommendations, with some more general and some targeted to specific roles in the process. The expert panel understood that there’s more than one right way to accomplish these goals, and they were trying not to be too prescriptive about how to do these things in a specific way, Ms. Fain said. The harder part is making sure everyone carries out whatever the team agrees to, she added.

One problem identified was that when there is a process that’s not standardized, each surgeon comes in with his or her own process, which requires the rest of the team to constantly adapt. This increases the likelihood that mistakes will be made, Ms. Fain said. One of the challenges with process improvement and the goal of creating highly reliable systems is you can put good systems in place, but you’re never really done, she said, and this proves true not only in ophthalmology and cataract surgery but across the practice of medicine.

Joseph Bayes, MD, anesthesiologist, Massachusetts Eye and Ear Infirmary, Boston, was a member of the panel. In terms of the problems of the wrong lens being implanted or surgery being done on the wrong eye, he said they recommended a formal lens management policy that defines uniform processes for verifying and ordering IOLs. The panel also recommended a uniform facility policy for marking the eye that is being operated on, using multiple patient identifiers and active verification, and a robust timeout between each step of the procedure. The second part of recommendations, Dr. Bayes said, related to anesthesia. The type of anesthesia should be discussed between the ophthalmologist and patient at the time of the decision to have surgery, he said. The anesthesiologist can say if he or she thinks any part of the plan is inappropriate, he said, but “we’re seeing patients after they’ve gone through a long preparation with their surgeon.” The second general recommendation was for everyone to stay current on evidence-based practice to minimize risk and harm.

Engaging the patient in decisions about anesthesia and strengthening onboarding of new contracting anesthesia staff are important recommendations, he said.

“The critical thing for me is to reinforce the importance of doing the timeout consistently and exactly the way it’s outlined to reduce the chance of errors,” he said. These complications are rare, but because there are so many cataract surgeries every year, they can occur. “We think we can reduce the incidence of these complications by following these recommendations,” Dr. Bayes said.

Katie Murphy, RN, nurse and practice administrator, Plymouth Laser and Surgical Center, Plymouth, Massachusetts, got involved with the study because of her experience both with state medical organizations and as an RN. “The percentage of incidents is low compared to the number of surgeries, but it’s still something that needs to be worked on and minimized,” Ms. Murphy said. Between technology and changing of staff, there are so many factors that can lead to an incident that this problem is going to be ongoing forever, she said, noting that she was, however, surprised at how many incidents there were.

After being on the panel, Ms. Murphy said she has a different view when looking throughout the surgery center because of everything that she learned about how mistakes are made. When you get busy and are pulled from one patient to the next, that’s when these errors can occur, she said.

Ms. Murphy said that some of the recommendations from the report have now been implemented in her practice, particularly taking “timeouts” when in the OR where everyone has to stop and focus.

Michael Morley, MD, retina specialist, Ophthalmic Consultants of Boston, served on the panel and was one of the co-chairs. He thinks the study is an important opportunity to “make ourselves better.” He said that these errors not only cause injury to the patients but also to the profession as a whole. Errors like the wrong lens being inserted, operating on the wrong patient, and the wrong eye being operated on are all big concerns. Dr. Morley said an active timeout—asking patients to state their name and date of birth, not asking them to simply nod yes to the question of who they are—can help reduce the risk of operating on the wrong patient, performing the wrong procedure, or operating on the wrong side. It’s also important that everyone on the clinical and administrative teams understands how they personally can reduce the chance for errors. Knowing where the “landmines” are can help avoid errors. Dr. Morley stressed the importance of developing a culture of safety both in the clinic and in the operating room. Implementing these suggestions is the most difficult part of the recommendations and requires leadership and communication. Physicians and senior managers must be committed to a culture of safety, leading by example and communicating that safety is a priority for the organization. Physicians who do a perfunctory timeout—or none at all—are sending a disheartening message to their staff who want to take pride in their work as the best possible providers of care. “Our focus now is to take this information and try to have a coordinated, repetitive program that repeatedly brings this information in a variety of formats and a variety of places,” he said. The goal is to reduce the incidence of these errors to zero.

The full report can be found at:

Editors’ note: The sources have no financial interests related to their comments.

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Report offers recommendations for handling adverse events in cataract surgery Report offers recommendations for handling adverse events in cataract surgery
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