There have been a surge of never events related to cataract procedures in Massachusetts, and findings from a non-regulatory state agency suggest that these events were largely preventable.
A panel of experts assembled by the Betsy Lehman Center for Patient Safety and Medical Error Reduction identified 28 severe errors involving cataract surgery that were reported to health officials in Massachusetts between 2011 and 2015. The four primary causes for these medical mishaps were implantation of an intraocular lens not intended for the patient, surgery on the wrong patient, surgery or anesthesia on the wrong eye and other anesthesia-related injuries.
In one of the more troublesome occurrences of error, five patients in 2014 were harmed in one day due to the malfeasances of one anesthesiologist who was on his second day of work at the facility. Some of those patients suffered vision loss.
The Lehman Center panel found that most of these events were the result of ineffective time outs and were largely preventable. The report provides action steps and recommendations throughout the care continuum to assist caretakers in limiting the risk of patient harm. Some the recommendations include avoiding hand-written orders for lenses, performing a two-person time out directly prior to the administration of anesthesia and standardizing all surgical markings to eliminate potential confusion.
Cataract surgery is the most common surgery performed in the U.S. According to the Boston Globe, 50 percent of Americans will develop vision-impairing cataracts by age 75. Last year, there were 4 million cataract-related procedures in the U.S.
Barbara Fain, executive director of the Lehman Center, told the Globe, "When you are talking about 4 million a year, even tiny rates of error turn into big numbers of patients harmed."
More articles on quality:
More donor kidneys go to waste on the weekends
FDA issues safety warning on side effects of popular antibiotics
3 ways virtual care clinics improve quality