"Surgical confusions (i.e., wrong patient, wrong site, wrong procedure) are an increasingly recognized cause of morbidity, recently representing the most common category of reportable medical error," the authors write as background information in the article.
"In July 2004, the Joint Commission on Accreditation of Healthcare Organizations, in concert with many professional organizations, including the American Academy of Ophthalmology, promulgated the Universal Protocol in an effort to prevent such confusions in all surgical procedures. This protocol includes consistent preoperative verification, site marking and a time-out immediately before incision."
John W. Simon, M.D., of the Lions Eye Institute, Albany Medical College, N.Y., and colleagues retrospectively analyzed 106 cases of surgical confusions involving eye operations that occurred between 1982 and 2005. This included 42 cases from the Ophthalmic Mutual Insurance Company and 64 from the New York State Health Department.
Their analysis found that:
· The most common confusion was wrong lens implants, which occurred in 67 of 106 cases (63 percent) and most often happened because lens specifications were not checked properly before implantation.
· The wrong eye was injected with anesthesia in 14 cases (13 percent) and operated on in 15 cases (14 percent).
· In eight cases, confusions involved the wrong patient or the wrong procedure.
· The wrong tissue was transplanted in two cases.
· Confusions involving the wrong implant or transplant more often caused severe injuries than those involving the wrong eye, patient or procedure.
· The Universal Protocol, if implemented, would have prevented 85 percent of the confusions.
The authors estimate that these data suggest a rate of 69 surgical confusions for every 1 million eye operations.
"The causes of these confusions were faulty systems, processes and conditions that led people to make mistakes, more often than an individual's recklessness," the authors write. "The traditional response to medical error, 'blame, shame and train,' therefore misses the point. Humiliating or otherwise disciplining caregivers tends to perpetuate a culture of secrecy that impedes effective root-cause analysis and future improvement.
A more enlightened approach is entirely non-punitive, drawing on methods of crew resource management adapted from the airlines and the defense department."