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Home E-Weekly November 14, 2017

What's Causing So Many Bad Cataract Surgery Outcomes?

Published: November 13, 2017

PROBLEM AREA Nearly half of the reported mishaps were associated with the placement of eye blocks.

Nearly 40 cataract patients suffered bad outcomes during a 5-year period in Massachusetts, prompting a panel of experts to come up with several standardized protocols and safety improvement practices in surgical facilities throughout the state.

Among the reported adverse events was the shocking account of 5 patients blinded in one morning at a cataract surgery center when an anesthesiologist is believed to have pierced their eyeballs or retinas while placing blocks.

The panel — comprised of anesthesiologists, ophthalmologists, medical administrators, patient safety experts and patient representatives — reviewed 37 adverse events that occurred between 2011 and 2015, including implantation of the wrong lens, eye block complications, blocking of the wrong eye, development post-op inflammation, retained objects, and wrong-patient or wrong-procedure mistakes. According to the panel, the events were caused by system failures or choice of anesthesia technique.

System failures included failing to follow proper safety protocols, miscommunication among staff members, inadequate training and a lack of standardization when labeling supplies or marking surgical sites. Notably, 15 of the 37 adverse events were associated with the placement of eye blocks; none of the events involved topical or general anesthesia.

Karen Nanji, MD, MPH, an assistant professor of anesthesia at Harvard Medical School and anesthesiologist at Massachusetts General Hospital in Boston, Mass., co-authored the panel's call for the use of standardized protocols during pre-op safety checks and surgical site marking as well as the least invasive form of anesthesia that's appropriate for individual patients.

"No medical procedure is immune from human error, and cataract surgery — one of the safest and most commonly performed procedures in the country — offers a clear case in point," says Dr. Nanji. "Errors leading to significant patient harm, and we must do more to prevent them. It is ultimately the responsibility of healthcare facilities and care teams to implement prevention strategies."

Daniel Cook

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