Intraocular Lens Confusions: A Preventable " Never Event" -The Royal Victorian Eye and Ear Hospital Protocol

Survey of Ophthalmology

Volumn 57, Issue 5, 2012, Pages 430-447

  Zamir, Ehud ^a,b   Beresova Creese, Katarina ^b   Miln, Linda ^b  

^a CENTRE FOR EYE RESEARCH AUSTRALIA   (Australia)

^b ROYAL VICTORIAN EYE AND EAR HOSPITAL   (Australia)

Author keywords

Cataract surgery; Intraocular lenses; Medical errors; Patient safety

Indexed keywords

AUSTRALIA; CATARACT EXTRACTION; CLINICAL PROTOCOL; CONFUSION; CONTACT LENS; HUMAN; KERATOMILEUSIS; LENS IMPLANT; LENS IMPLANTATION; MALPRACTICE; MEDICAL PRACTICE; MEDICOLEGAL ASPECT; OPHTHALMOLOGY; PATIENT SAFETY; POSTOPERATIVE COMPLICATION; PREOPERATIVE PERIOD; PRIORITY JOURNAL; REFRACTION ERROR; REVIEW; SPECTACLES; SURGICAL ERROR; CLINICAL PATHWAY; HOSPITAL; MEDICAL ERROR; PRACTICE GUIDELINE; STANDARD;

CATARACT EXTRACTION; CLINICAL PROTOCOLS; CRITICAL PATHWAYS; HOSPITALS, SPECIAL; HUMANS; LENS IMPLANTATION, INTRAOCULAR; LENSES, INTRAOCULAR; MEDICAL ERRORS; OPHTHALMOLOGY; PRACTICE GUIDELINES AS TOPIC; VICTORIA;

EID: 84865164489     PISSN: 00396257     EISSN: 18793304     Source Type: Journal    
DOI: 10.1016/j.survophthal.2011.12.003     Document Type: Review

References (40)

1. Ali N. A decade of clinical negligence in ophthalmology. BMC Ophthalmol 2007, 7:20.
2. Ali N., Little B.C. Causes of cataract surgery malpractice claims in England 1995-2008. Br J Ophthalmol 2011, 95:490-492.
3. To Err is Human: Building a Safer Health Care System 1999, American Institute of Medicine Committee on Quality of Health Care in America, National Academy Press, Washington, DC. L. Kohn, J. Corrigan, M. Donaldson (Eds.).
4. Benn J., Koutantji M., Wallace L., et al. Feedback from incident reporting: information and action to improve patient safety. Qual Saf Health Care 2009, 18:11-21.
5. Cima R.R., Kollengode A., Garnatz J., et al. Incidence and characteristics of potential and actual retained foreign object events in surgical patients. J Am Coll Surg 2008, 207:80-87.
6. Clarke J.R., Johnston J., Finley E.D. Getting surgery right. Ann Surg 2007, 246:395-403. discussion 405.
7. Eleftheriadis H., Marcantonio J., Duncan G., et al. Interlenticular opacification in piggyback AcrySof intraocular lenses: explantation technique and laboratory investigations. Br J Ophthalmol 2001, 85:830-836.
8. Gawande A. The Checklist Manifesto. How to Get Things Right 2010, Profile Books Ltd, London. ed 1.
9. Gawande A.A., Studdert D.M., Orav E.J., et al. Risk factors for retained instruments and sponges after surgery. N Engl J Med 2003, 348:229-235.
10. Gayton J.L., Van der Karr M., Sanders V. Neodymium:YAG treatment of interlenticular opacification in a secondary piggyback case. J Cataract Refract Surg 2001, 27:1511-1513.
11. Habot-Wilner Z., Sachs D., Cahane M., et al. Refractive results with secondary piggyback implantation to correct pseudophakic refractive errors. J Cataract Refract Surg 2005, 31:2101-2103.
12. Haynes A.B., Weiser T.G., Berry W.R., et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009, 360:491-499.
13. Holladay J.T. Standardizing constants for ultrasonic biometry, keratometry, and intraocular lens power calculations. J Cataract Refract Surg 1997, 23:1356-1370.
14. Hsiang J. Wrong-level surgery: a unique problem in spine surgery. Surg Neurol Int 2011, 2:47.
15. Jin G.J., Merkley K.H., Crandall A.S., et al. Laser in situ keratomileusis versus lens-based surgery for correcting residual refractive error after cataract surgery. J Cataract Refract Surg 2008, 34:562-569.
16. Kachalia A., Kaufman S.R., Boothman R., et al. Liability claims and costs before and after implementation of a medical error disclosure program. Ann Intern Med 2010, 153:213-221.
17. Keatings M., Martin M., McCallum A., et al. Medical errors: understanding the parent's perspective. Pediatr Clin North Am 2006, 53:1079-1089.
18. Kelly S.P., Astbury N.J. Patient safety in cataract surgery. Eye (Lond) 2006, 20:275-282.
19. Kelly S.P., Jalil A. Wrong intraocular lens implant; learning from reported patient safety incidents. Eye (Lond) 2011, 25:730-734.
20. Kingston M.J., Evans S.M., Smith B.J., et al. Attitudes of doctors and nurses towards incident reporting: a qualitative analysis. Med J Aust 2004, 181:36-39.
21. Kreckler S., Catchpole K., McCulloch P., et al. Factors influencing incident reporting in surgical care. Qual Saf Health Care 2009, 18:116-120.
22. Kwaan M.R., Studdert D.M., Zinner M.J., et al. Incidence, patterns, and prevention of wrong-site surgery. Arch Surg 2006, 141:353-357. discussion 7-8.
23. Lawton R., Parker D. Barriers to incident reporting in a healthcare system. Qual Saf Health Care 2002, 11:15-18.
24. Lee A.C., Qazi M.A., Pepose J.S. Biometry and intraocular lens power calculation. Curr Opin Ophthalmol 2008, 19:13-17.
25. Lincourt A.E., Harrell A., Cristiano J., et al. Retained foreign bodies after surgery. J Surg Res 2007, 138:170-174.
26. Mahajan R.P. Critical incident reporting and learning. Br J Anaesth 2010, 105:69-75.
27. Michaels R.K., Makary M.A., Dahab Y., et al. Achieving the National Quality Forum's " Never Events" : prevention of wrong site, wrong procedure, and wrong patient operations. Ann Surg 2007, 245:526-532.
28. Neily J., Mills P.D., Eldridge N., et al. Incorrect Surgical procedures within and outside of the operating room: a follow-up report. Arch Surg 2011, 146:1235-1239.
29. Neily J., Mills P.D., Eldridge N., Dunn, et al. Incorrect surgical procedures within and outside of the operating room. Arch Surg 2009, 144:1028-1034.
30. Neily J., Mills P.D., Young-Xu Y., et al. Association between implementation of a medical team training program and surgical mortality. JAMA 2010, 304:1693-1700.
31. Panel P., Cabarrot P. [Do we need a surgical safety checklist?]. J Gynecol Obstet Biol Reprod (Paris) 2010, 39:362-370.
32. Panesar S.S., Carson-Stevens A., Fitzgerald J.E., et al. The WHO surgical safety checklist-junior doctors as agents for change. Int J Surg 2010, 8:414-416.
33. Reason J. Safety in the operating theatre-Part 2: human error and organisational failure. Curr Anaesth Crit Care 1995, 6:121-126.
34. Rogers S.O., Gawande A.A., Kwaan M., et al. Analysis of surgical errors in closed malpractice claims at 4 liability insurers. Surgery 2006, 140:25-33.
35. Sari A.B., Sheldon T.A., Cracknell A., et al. Sensitivity of routine system for reporting patient safety incidents in an NHS hospital: retrospective patient case note review. BMJ 2007, 334:79.
36. Seiden S.C., Barach P. Wrong-side/wrong-site, wrong-procedure, and wrong-patient adverse events: are they preventable?. Arch Surg 2006, 141:931-939.
37. Simon J.W. Preventing surgical confusions in ophthalmology (an American Ophthalmological Society thesis). Trans Am Ophthalmol Soc 2007, 105:513-529.
38. Simon J.W., Ngo Y., Khan S., et al. Surgical confusions in ophthalmology. Arch Ophthalmol 2007, 125:1515-1522.
39. Soar J., Peyton J., Leonard M., et al. Surgical safety checklists. BMJ 2009, 338:b220.
40. Taleb N.N. The Black Swan 2007, Random House, New York. ed 1.