Eyeworld

83 OPHTHALMOLOGY BUSINESS May 2017 digital.ophthalmologybusiness.org same power, but for the correct eye, and wait until that implant was brought to the operating room with the correct paperwork for the correct eye," he said. "Rather than skipping that step in the interest of expedi- ency and moving along and doing surgery, that would have been the correct thing to do. Would I have done it? I don't know, but I hope that I would have." EW References 1. Institute of Medicine Committee on Quality of Health Care in America. To Err Is Human: Building a Safer Health System. 2000. National Academies Press. 2. Stelfox HT, et al. The "To Err is Human" report and the patient safety literature. Qual Saf Health Care. 2006;15:174–8. 3. Paterick ZR, et al. The challenges to trans- parency in reporting medical errors. J Patient Saf. 2009;5:205–9. Editors' note: Drs. Custer and Foster have no financial interests related to their comments. Contact information Custer: custer@wustl.edu Foster: sfoster@mersi.com gery went forward and the outcome was positive. However, the team still created an incident report. The director of surgery spoke with those involved and, while that might seem like it settled the matter, Dr. Foster said an investigation ended up being mounted by the surgery center's chairman of the board. "In the end, it all came to nothing, but there was such concern about this breakdown in the process and this simple thing of paperwork that didn't match what was going to be done," Dr. Foster said. "That's how serious people take things today. It can look like much ado about nothing, but everyone takes it so seriously that they want to nail it down, button it up, and make sure that the systems in place are so airtight that nothing can occur." When asked to put himself into this surgeon's shoes, what would he have done? Dr. Foster said he isn't sure. "I know the bureaucratically correct thing to do would have been to cancel the case—not necessarily send the patient home, but delay— redo the request for the implant, this reporting is taken. The story involved a surgeon with a bilateral cataract patient. The first eye was operated on in an uneventful, suc- cessful surgery. A month later when it came time for the second cataract surgery, a nurse noticed the IOL power was the same for this eye as it was the previously operated upon eye. In other words, both eyes were the same and required the same " Many times staff will see something going on that you had no idea was happening, or they'll have good suggestions. As a specialty, we need to become more educated about how you address safety and make improvements. " —Philip Custer, MD ASCRS IOL power. However, on the case paperwork in the OR, the eye slated in print to receive this IOL was the wrong eye; the one already operated on was the one on paper. Dr. Foster said the surgeon and staff consulted and ultimately rea- soned that the implant was correct and there was a mistake on the paperwork as to which eye. The sur-

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