Eyeworld

by Liz Hillman, Staff Writer "Getting right and left confused is a very common human error," Dr. Dutt said, explaining that while the app, which works for iPhone and iPads, can be used for any surgery or procedure, it is most useful for bilat- eral surgical sites, such as eyes. A separate review of such inci- dents specifically in ophthalmology published in Archives of Ophthalmol- ogy in 2007 found that "relatively little information is available regard- ing the incidence and severity of the problem in ophthalmology." 2 Of the surgical confusion cases that were reported, more than half involved the wrong implant, rather than the wrong site, wrong patient, or wrong procedure. The study reviewed 106 cases recorded by the Ophthalmic Mutual Insurance Company and the New Your State Health Department be- tween 1982 and 2005 and found 63% of these cases involved the wrong lens implants. Fifteen cases involved surgery in the wrong eye, followed by 14 wrong eye blocks, 8 wrong patient/procedure cases, and 2 wrong corneal transplants. Dr. Dutt has been using the Site of Surgery Assistant in his own prac- tice and said the app and bracelet can include specifics about intraocular lenses, if applicable. What's more, the app provides another opportuni- ty for patient involvement. "[Patients] feel that they are par- ticipating in the surgical process in- stead of just signing papers," he said. "They feel reassured that the correct site has been selected. They feel that the office is using the latest tools for their safety." There are, of course, already es- tablished protocols and procedures to prevent surgical errors. such as wrong site, wrong procedure, or wrong patient. Dr. Dutt, Eyecare Centers of Florida, Brooksville, Florida, creat- ed a new app—the Site of Surgery Assistant—that seeks to reduce what he calls "never events" by featur- ing a marked picture of the surgical site and other pertinent details on a patient's wristband, which would otherwise only include the basics like name, birth date, and physician. The site of surgery picture could be printed on chart forms and adhesive labels as well. According to an article published in the Journal of the American Medical Associa- tion (JAMA) in 2015, 1 wrong-site sur- gery event occurs in every 100,000 surgeries. 1 "Errors can occur anywhere in the steps leading to surgery, such as in office paperwork, surgery center paperwork, preop check-in, and in the operating room. Having a visual guide is an intuitive way of rapidly and accurately determining the cor- rect site," Dr. Dutt said, adding that both the patient and the surgeon mark their approval of the site and other surgery details, reinforcing accuracy and affirming informed consent. Perhaps 1 of the most common mistakes the app is designed to prevent is right and left confusion. Site of Surgery Assistant places picture and surgical details on patient's wristband S ome say a picture is worth a thousand words. Srin Dutt, MD, says a "picture is worth a thousand checklists"—that is, if you're talking about preventing surgical errors New app seeks to reduce 6 Ophthalmology Business • July 2016

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