From the Betsy Lehman Center for Patient Safety, Boston, Massachusetts.
Department of Anesthesia, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts.
Anesth Analg. 2018 May;126(5):1548-1550. doi: 10.1213/ANE.0000000000002526.
Massachusetts state agencies received reports of 37 adverse events (AEs) involving cataract surgery from 2011 to 2015. Fifteen were anesthesia related, including 5 wrong eye blocks, 3 cases of hemodynamic instability, 2 retrobulbar hematoma/hemorrhages, and 5 globe perforations resulting in permanent loss of vision. While Massachusetts' reported AEs likely underrepresent the true number of AEs that occur during cataract surgery, they do offer useful signal data to indicate the types of patient harm occurring during these procedures.
马萨诸塞州各机构在 2011 年至 2015 年间收到了 37 起与白内障手术相关的不良事件报告。其中 15 起与麻醉相关,包括 5 例错误的眼部阻滞、3 例血流动力学不稳定、2 例球后血肿/出血,以及 5 例导致永久性视力丧失的眼球穿孔。虽然马萨诸塞州报告的不良事件可能低估了白内障手术过程中实际发生的不良事件数量,但它们确实提供了有用的信号数据,表明这些手术过程中发生的患者伤害类型。