October 2018

CATARACT

Presentation spotlight
Cataract surgery would be well served by cockpit discipline


by Stefanie Petrou Binder, MD, EyeWorld Contributing Writer


With a single pilot crew, multitasking is necessary: navigation, communication, awareness, and flying the plane. The situation is similar in cataract surgery.

When instructing beginners, the exact plan is written, and time is reserved for every exercise by the aviation training organization. All the trainees have to pass the same training.
Source (all): Vladimir Pfeifer, MD


“In aviation in general, we have checklists. Every procedure that is done goes through a mandatory checklist, beginning with starting the plane and taking off. We should also do this in our operating rooms.”
—Vladimir Pfeifer, MD

Checklists and routine safety reports promote increased safety and fewer mistakes in cataract surgery

Safety precautionary measures should be much the same in cataract surgery as in aviation, according to a presentation given at the 22nd ESCRS Winter Meeting. Like in medicine, the aviation industry addresses technical, human, and organizational factors to maintain utmost safety. According to Vladimir Pfeifer, MD, University Eye Hospital, Ljubljana, Slovenia, who is also a pilot and spoke on the topic of “The pilot and the cataract surgeon: minimizing risk and avoiding complications,” there needs to be a careful balance between protection and production. If production outweighs protection, aviation safety may be in jeopardy. The same is true of the opposite; if protection costs too much, the company can go bankrupt.
“Flight companies have safety controls that reduce the possibility of an undesirable hazardous event,” Dr. Pfeifer said. “The safety controls reduce the severity of a hazardous consequence and eliminate or diminish hazards. If they do occur, there are tools used to mitigate the occurrence or potential outcome, so things do not turn out as bad as they might. Taking an example from aviation, I think we should bring these things into medicine, especially into the operating room.”
Airlines have a system by which they score different types of events according to their safety/risk probability. The scores reflect the frequency with which events are encountered (frequent to inconceivable) and their severity, which grades events as catastrophic, hazardous, major, minor, and negligible. A catastrophic event is associated with multiple deaths and the destruction of equipment. Hazardous events are associated with a large reduction in safety margins with serious injuries. A major event means a significant reduction in safety margins and a reduction in the ability of the operators to cope with adverse operating conditions as a result of an increase in workload or resulting from conditions that impair their efficiency. Minor and negligible events present far less challenges to overall safety and can be dealt with more easily.
“These factors are assessed together and graded from 5A, a frequent catastrophic risk, to 5E, a frequent risk of negligible importance, to 1A, an extremely improbable risk of catastrophic proportions, to 1E, an extremely improbable risk of negligible repercussions, and everything in between,” Dr. Pfeifer explained. “The risks fall into three basic categories: acceptable, tolerable, and unacceptable. Tolerable risks require management decisions and are based on risk mitigation, while unacceptable risks cannot be allowed to occur.”
Safety reporting in medicine needs to follow similar guidelines. “Safety reporting is very important,” Dr. Pfeifer said. “In aviation, if someone reports an event, it is analyzed to prevent it from happening again. This should happen in medicine. People are knowledgeable about the human, technical, and organizational factors that determine the safety of a system as a whole and need to report events that affect safety. Effective safety reporting is associated with information, flexibility, learning, accountability, and willingness.”
He explained that airlines have both voluntary and mandatory safety reports, some of which are anonymous. This allows airline personnel to report events, without individuals suffering the consequences, and help build up security to a higher level. Reports include voluntary safety reports, occurrence reports, safety improvement reports, suggestions, hazard/ risk reports, and identification reports.
Every step of the way leading up to and away from a flight has mandatory documentation and checklists. Dr. Pfeifer said, “In aviation in general, we have checklists. Every procedure that is done goes through a mandatory checklist, beginning with starting the plane and taking off. We should also do this in our operating rooms. We have standard operating procedures, and we need to write down the procedure for every surgery and check things off one by one. This procedure is standard in Slovenia for all doctors, nurses, and technicians. There are also standard protocols for machine calibration, etc. Each machine has detailed instructions for use, so there cannot be unnecessary confusion. In medicine, however, unlike aviation, it can be difficult to persuade personnel to adhere to check lists, and consequently, things can be forgotten.”
Effective safety management is data driven. The sound management of an organization’s databases is fundamental to ensuring the effective and reliable safety analysis of consolidated sources of data. The establishment and maintenance of a safety database provide an essential tool for personnel monitoring system safety issues. Dr. Pfeifer observed that a wide range of relatively inexpensive electronic databases capable of supporting an organization’s data management requirements are commercially available. Depending on the size and complexity of the organization, system requirements include capabilities to effectively manage safety data. In general, the system should: have user friendly data entry, be able to transform large amounts of safety data into useful information that supports decision making, reduce the workload for managers and personnel, and operate at relatively low cost.
“Surgical steps are also spelled out on the checklist, so the nurse can remind us and the other nurses of completed and upcoming steps in the procedure,” Dr. Pfeifer said. “At the operating table, we identify the patient on the operating table. We make sure to identify the eye that needs to be operated, which lens will be used, what the refraction is, etc. Also, the operating work place needs to be practical and comfortable, for the surgeon and the patient. The surgeon needs good back support, and holding the phaco handpiece and I/A should be comfortable and secure. Emergency procedures are on the doors of the cabinet in the OR. No one should have to rely on memory in case of emergency.”
Dr. Pfeifer said that skill and procedure adherence are hallmarks of both the pilot and the cataract surgeon. “We teach young people how to fly and we teach young people how to perform cataracts. The procedures are similar. We should allow young candidates to learn, and although we know when they are going to make a mistake, we need to allow them more time to realize and find out on their own, before we stop them. Meanwhile, our checklists are in place to ensure high safety for our patients,” he explained.

Editors’ note: Dr. Pfeifer has no financial interests related to his comments.

Contact information

Pfeiffer
: pfeifer@pfeifer.si

Cataract surgery would be well served by cockpit discipline Cataract surgery would be well served by cockpit discipline
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