Risk Management and Patient Safety Unit, Assuta Hospital, Ramat Hachayal, Tel-Aviv, Israel.
Research Wing, Ziv Medical Center, Safed, Israel ; Tel-Hai Academic College, Upper Galilee, Israel.
Risk Manag Healthc Policy. 2014 Apr 8;7:77-80. doi: 10.2147/RMHP.S60728. eCollection 2014.
Because wrong-site confusion is among the most common mistakes in the operations of paired organs, we have examined the frequency of wrong-sided confusions that could theoretically occur in cataract surgeries in the absence of preoperative verification.
Ten cataract surgeons participated in the study. The surgeons were asked to complete a questionnaire that included their demographic data, occupational habits, and their approach to and the handling of patients preoperatively. On the day of operation, the surgeons were asked to recognize the side of the operation from the patient's name only. At the second stage of the study, surgeons were asked to recognize the side of the operation while standing a 2-meter distance from the patient's face. The surgeons' answers were compared to the actual operation side. Patients then underwent a full time-out procedure, which included side marking before the operation.
Of the total 67 patients, the surgeons correctly identified the operated side of the eye in 49 (73%) by name and in 56 (83%) by looking at patients' faces. Wrong-side identification correlated with the time lapsed from the last preoperative examination (P=0.034). The number of cataract surgeries performed by the same surgeon (on the same day) also correlated to the number of wrong identifications (P=0.000). Surgeon seniority or age did not correlate to the number of wrong identifications.
This study illustrates the high error rate that can result in the absence of side marking prior to cataract surgery, as well as in operations on other paired organs.
由于错侧混淆是配对器官手术中最常见的错误之一,因此我们检查了在没有术前验证的情况下,白内障手术中可能理论上发生的错侧混淆的频率。
十位白内障外科医生参与了这项研究。要求外科医生填写一份问卷,内容包括他们的人口统计学数据、职业习惯以及他们术前对患者的处理方式。在手术当天,外科医生仅根据患者的姓名来识别手术侧。在研究的第二阶段,外科医生被要求在距离患者面部两米的距离处识别手术侧。将外科医生的答案与实际手术侧进行比较。然后,患者接受了全面的暂停程序,包括手术前的侧标。
在总共 67 名患者中,外科医生通过姓名正确识别了 49 名(73%)患者的手术眼,通过观察患者的面部正确识别了 56 名(83%)患者的手术眼。错误侧识别与上次术前检查的时间间隔有关(P=0.034)。同一外科医生(同一天)进行的白内障手术数量也与错误识别数量相关(P=0.000)。外科医生的资历或年龄与错误识别数量无关。
这项研究说明了在白内障手术或其他配对器官手术前不进行侧标时可能导致的高错误率。