EW NEWS & OPINION
November 2016
21
The full report can be found at:
www.betsylehmancenterma.gov/
initiatives-and-research-medical-
errors-massachusetts/cataract-
surgery-report-massachusetts. EW
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 opportu-
nity 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 pro-
cedure, or operating on the wrong
side. It's also important that every-
one on the clinical and administra-
tive teams understands how they
personally can reduce the chance for
errors. Knowing where the "land-
mines" are can help avoid errors.
Dr. Morley stressed the impor-
tance 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 commu-
nication. 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. Physi-
cians who do a perfunctory time-
out—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 co-
ordinated, 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.
Editors' note: The sources have
no financial interests related to
their comments.
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Contact information
Bayes: Joseph_Bayes@meei.harvard.edu
Fain: barbara.fain@state.ma.us
Morley: michaelgmorley@gmail.com
Murphy: kmurphy@eyeboston.com
