Massachusetts Eye and Ear Infirmary, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts; Manhattan Retina and Eye Consultants, New York, New York; Department of Ophthalmology, New York University, New York, New York.
Massachusetts Eye and Ear Infirmary, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts; Northeastern University, Boston, Massachusetts.
Ophthalmology. 2020 Mar;127(3):296-302. doi: 10.1016/j.ophtha.2019.07.013. Epub 2019 Jul 17.
To characterize surgical confusions in ophthalmology to determine their incidence, root causes, and impact on patients and physicians.
Retrospective cohort study of errors in ophthalmic surgical procedures between January 1, 2006, and December 31, 2017.
One hundred forty-three cases involving surgical confusions.
Cases were identified by the Ophthalmic Mutual Insurance Company from closed case files and by the New York State Health Department from the New York Patient Occurrence Reporting and Tracking program that identified the surgical confusions.
Incidence and impact by intended surgery, error type, and root cause as well as preventability by the Universal Protocol.
Of the 143 cases of surgical confusions identified, 92 cases (64.3%) were deemed preventable by the Universal Protocol. Approximately two thirds, 95 cases (66.4%), were cases of incorrect implants being used during cataract surgery (cataract extraction and intraocular lens implantation), of which 33 cases (34.7%) were not preventable by the Universal Protocol. Wrong eye blocks or anesthesia accounted for 20 cases (14.0%), incorrect eye procedures accounted for 10 cases (7.00%), incorrect refractive surgery measurements accounted for 6 cases (4.20%), incorrect patient or procedure accounted for 5 cases (3.50%), incorrect intraocular gas concentration accounted for 4 cases (2.80%), and incorrect medication in surgery accounted for 3 cases (2.10%). The most common root cause of confusion was an inadequately performed time out, which was responsible for nearly one third of all surgical confusions, 46 cases (32.2%). Incorrect lens orders or calculations before surgery (so-called upstream errors) were the second most common cause of surgical confusion, involving 31 cases (21.7%). The average legal indemnity for incorrect implant during cataract surgery was $57 514 (United States dollars). The average indemnity for incorrect refractive surgery measurement was $123 125, that for incorrect eye procedure was $50 000, and that for incorrect gas concentration was $220 844.
Most surgical confusions could have been prevented by following the Universal Protocol properly. However, upstream errors, originating in the clinic or office before surgery, and ineffective communication during time outs suggest a need for modification of the Universal Protocol.
描述眼科手术中的混淆情况，以确定其发生率、根本原因以及对患者和医生的影响。
对 2006 年 1 月 1 日至 2017 年 12 月 31 日期间眼科手术失误的病例进行回顾性队列研究。
涉及手术混淆的 143 例病例。
通过眼科互助保险公司从封存的病例档案中以及纽约州卫生部门从纽约患者事件报告和跟踪计划中确定手术混淆的情况，识别出病例。
按预期手术、错误类型和根本原因以及通用协议的可预防性计算的发生率和影响。
在确定的 143 例手术混淆中，92 例（64.3%）被认为可通过通用协议预防。大约三分之二，95 例（66.4%）是在白内障手术（白内障摘除和人工晶状体植入）中使用错误植入物的情况，其中 33 例（34.7%）不能通过通用协议预防。错误的眼部阻滞或麻醉占 20 例（14.0%），错误的眼部手术占 10 例（7.00%），错误的屈光手术测量占 6 例（4.20%），错误的患者或手术占 5 例（3.50%），错误的眼内气体浓度占 4 例（2.80%），手术中错误的药物占 3 例（2.10%）。混淆的最常见根本原因是超时操作不当，导致近三分之一的手术混淆，共 46 例（32.2%）。手术前不正确的镜片订单或计算（所谓的上游错误）是手术混淆的第二大常见原因，涉及 31 例（21.7%）。白内障手术中植入物错误的平均法律赔偿额为 57514 美元（美元）。错误的屈光手术测量的平均赔偿额为 123125 美元，错误的眼部手术的赔偿额为 50000 美元，错误的气体浓度的赔偿额为 220844 美元。
大多数手术混淆本可以通过正确遵循通用协议来预防。然而，起源于术前诊所或办公室的上游错误以及超时操作期间无效的沟通表明需要修改通用协议。
