Eyeworld

EW INTERNATIONAL 112 September 2016 by Vanessa Caceres EyeWorld Contributing Writer Some contributing factors to errors included: • changes in staff members during surgeries, frequently accompanied with a communication break- down; • errors connected with electronic patient records, such as access- ing incorrect patient records or incorrect eye data (these errors led to incorrect IOL selection and a failure to refer to source electronic record documents); and • changes to the planned procedure because of a change in the order of surgery or because of an intra- operative complication. "We were surprised by how many mistakes involved incorrect transcription of the selected IOL to other sources and subsequent failure to refer to original source docu- ments," Dr. Steeples said. "The cur- rent safety processes do not protect against mistakes cascading through the pathway, resulting in wrong IOL implantation." Most errors were identified postoperatively; the most common method of detection was via a refrac- tive surprise. The majority of errors were not associated with any patient harm (level of harm was required for reporting); however, four cases were reported as low harm, 12 as moder- ate, and three as severe. The authors of a 2015 report from researchers at the Veterans Health Administration (VHA) that tracked IOL errors said the find- ings in the U.K. are similar to their own. 3 In the VHA study, the most frequently mentioned reason was an incomplete pre-procedure time- out and failure to perform a double check of the pre-procedural calcu- lations based on original data and implant read-back at the time the surgical eye implant was performed. "Although there are many factors that may lead to implant errors, and some of the reasons were labeled differently between our study and this one, several import- ant issues stood out in both, such as the need to use original source docu- mentation and to avoid transcribing implant information," said Amy Chomsky, MD, Veterans Health Administration, Tennessee Valley assessment of the epidemiology of medical errors … mandatory report- ing of incidents since 2010 along- side a better reporting culture may explain the apparent higher rate in the later data." Types of errors The most common types of errors found were transcription errors (26 cases), wrong patient biome- try data (21 cases; this was an area with a large increase compared to the authors' last report), wrong IOL selected (16 cases), and wrong IOL brought into the operating area (12 cases). Other types of errors included right/left eye confusion, confusion of plus/minus power, communica- tion errors, a change in list order, and a complicated surgery—all with eight or nine cases. There were five or fewer cases of biometry error, wrong patient med- ical notes, handwriting misinterpre- tations, and wrong IOL in the box. FRCOphth, consultant ophthalmol- ogist, Manchester Royal Eye Hospi- tal, Central Manchester Foundation Trust, Manchester, U.K. Study details Investigators retrospectively ana- lyzed "wrong IOL" patient safety incidents reported to the NRLS from February 2010 to May 2014. They analyzed information provided to best determine the causes of the errors, and they compared the infor- mation with data collected by their group from 2003 to 2010. 2 The 178 cases found compared with 164 during their last analysis. However, there were also slightly more surgeries in the 2010 to 2014 period. Still, "attempts to direct- ly compare the rate of wrong IOL events between these two periods can be misleading," the authors wrote. "The true incidence of wrong IOL implantation is unknown as incident reporting systems do not necessarily provide an accurate U.K. analysis finds low error rate but prevalence of some common mistakes I t takes a team effort to avoid IOL implantation mistakes during cataract surgery. A study published in the the journal Eye discussed the value of team training while also sharing data on IOL errors from the United Kingdom's National Report- ing and Learning System (NRLS). 1 Although they only found 178 errors, the results reveal a need for better systems to avoid further errors. "Analysis of the causal factors in our results and elsewhere indi- cates that human, non-technical factors are the predominant caus- es of mistakes and have persisted despite significant patient safety initiatives, including surgical safety checklists," said lead study inves- tigator Laura Steeples, MBChB, Tracking and avoiding IOL errors

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