Eyeworld

OPHTHALMOLOGY BUSINESS 82 May 2017 by Liz Hillman EyeWorld Staff Writer Create confidence in reporting medical errors airtight that it wouldn't allow for hiding any errors and makes the reporting of incidents standard and routine. Dr. Foster described a protocol that many physicians in ophthal- mology and surgical staff employ to prevent wrong patient, wrong surgery, or wrong eye incidents. At several points preoperatively, the patient's name and date of birth are repeated along with the surgeon handling the case, the surgery to be performed, on which eye, etc. What's more, Dr. Foster said there are always two people looking through the operating microscope— both surgeons or a surgeon and scrubbed technician. "It would be impossible for any kind of a complication or surgical error to occur without it being wit- nessed," he said. If an error at any stage were to occur, Dr. Foster said an incident report is created with input from all those privy to whatever went wrong. An investigation, depending on the severity of the error, would go from there. Dr. Foster shared a story that he heard but has no first-hand knowl- edge of that shows how seriously publications on the topic of patient safety, "the extent to which 'To Err Is Human" has improved the safety of patients cannot be determined by the results of our study. A window of opportunity remains for health care to follow other high risk industries in establishing basic safety struc- ture." Paterick et al. published an arti- cle in the Journal of Patient Safety in 2009 detailing barriers to transpar- ent reporting in medicine. 3 "As long as physicians perceive that they are at risk for sanctions, malpractice claims, and unpredict- able compensation of injured pa- tients as determined by the United States' tort law system, legislative or regulative reform is unlikely to affect the underreporting of medical errors, and patient safety cannot benefit from the lessons derived from past medical errors and near misses," Paterick et al. concluded. C. Stephen Foster, MD, found- er and president, Massachusetts Eye Research and Surgery Institu- tion, and The Ocular Immunology & Uveitis Foundation, Waltham, Massachusetts, said the system at his ambulatory surgery center, where he is co-owner with 21 others, is so Once a tone of open commu- nication is set, Dr. Custer said the focus can be brought to addressing safety and quality issues. "Many times staff will see some- thing going on that you had no idea was happening, or they'll have good suggestions," he said. "As a specialty, we need to become more educated about how you address safety and make improvements." Several years after the release of the Institute of Medicine report, Stelfox et al. researched the effect of this document's publication on patient safety articles and allocation of federal funds to patient safety research. 2 Overall, they saw a "large shift in the number of patient safety publications" after the report was issued, as well as an increase in patient safety research. Federally funded research on the issue also increased following the report. "Before publication of the report, the most frequent subject of patient safety publications was mal- practice; after its release, the most frequent subject was organizational structure," Stelfox et al. wrote. While the authors of this article concluded that the Institute of Med- icine's report increased research and "T o Err Is Human"— That's the title of a report released by the Institute of Medicine that suggested up to 98,000 people die in U.S. hospitals as the result of other- wise preventable medical errors. 1 The instinct to hide one's error is also human, according to Philip Custer, MD, professor of ophthalmology and visual scienc- es, Washington University School of Medicine, St. Louis, even if this initial instinct is not acted upon. But to learn from mistakes and reduce incidence of future adverse medical events by making changes to the system requires a transparent report- ing system. How to create an atmosphere or culture where errors can be reported openly without fear is a challenge, Dr. Custer said. "I think it's natural for us to want to allocate responsibility and place blame, and I think none of us want to cause a problem, none of us want to harm a patient. We're all going to be embarrassed if we have any issue, and because of that, there is going to be a tendency to want to minimize embarrassment by either not reporting it or limiting your role in it, that's human nature," Dr. Custer said. As such, Dr. Custer said the administration of a practice or larger institution needs to set the tone for creating an open culture and lead by example. "Do you have open commu- nication among your staff where any member of that staff can offer a suggestion or point out a prob- lem, whether it be a safety issue or efficiency or something that needs maintenance?" Dr. Custer said, add- ing that this atmosphere can differ under various management styles. "We've all heard of situations where you keep your mouth shut; you are not rewarded for pointing out a problem." A culture where reporting is open and encouraged can identify weakness in the system and improve patient safety overall

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