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Journal Article > Commentary
Building a culture of safety in ophthalmology.
Custer PL, Fitzgerald ME, Herman DC, et al. Ophthalmology. 2016;123(suppl 9):S40-S45.
Efforts to reduce medical errors in ophthalmology often focus on cataract surgery, a high-volume procedure. This commentary explores how a culture of safety affects ophthalmic care, including its influence on error disclosure, teamwork, and failure analysis. The authors also describe initiatives that integrate core safety concepts into professional development programs for the specialty.
Newspaper/Magazine Article
5 cataract surgeries, 5 people blinded: what went wrong?
Kowalczyk L. Boston Globe. August 14, 2016.
Certain elements of the ambulatory surgery environment can increase risk of adverse events. Reporting on a series of patient injuries linked to a contracted anesthesiologist at a cataract surgery center, this news article describes how factors such as production pressure and insufficient assessment of contract anesthesiologists' qualifications can contribute to adverse events in outpatient surgery.
Book/Report
Advancing Patient Safety in Cataract Surgery: A Betsy Lehman Center Expert Panel Report.
Boston, MA: Betsy Lehman Center for Patient Safety and Medical Error Reduction; 2016.
Cataract surgery, one of the most common procedures in the United States, is vulnerable to wrong-site errors. This consensus report reviews the types of errors associated with cataract surgery and discusses evidence-based practices to reduce risks.
Journal Article > Commentary
Saying "I'm sorry": error disclosure for ophthalmologists.
Lee BS, Gallagher TH. Am J Ophthalmol. 2014;158:1108-1110.
This commentary spotlights elements of ophthalmology practice that can influence error disclosure, particularly the prevalence of patients receiving care from optometrists outside the hospital environment with no central reporting mechanism.
Journal Article > Study
"It is the left eye, right?"
Pikkel D, Sharabi-Nov A, Pikkel J. Risk Manag Healthc Policy. 2014;7:77-80.
In this study, cataract surgeons were asked to identify the correct eye for surgery when given the patient's name only, and again while looking at the patient's face. The surgeons answered incorrectly approximately a quarter of the time, arguing for the importance of preoperative time outs to avoid wrong-site surgery.
Newspaper/Magazine Article
Durasal–Durezol mix-up illustrates how dangerous product problems persist long after recognition.
ISMP Medication Safety Alert! Acute Care Edition. September 22, 2011;16:1-3.
This newsletter article reveals system failures that contribute to continued drug name confusion, even after authorities have been notified of the problem.
Journal Article > Study
Surgical confusions in ophthalmology.
Simon JW, Ngo Y, Khan S, Strogatz D. Arch Ophthalmol. 2007;125:1515-1522.
This retrospective study reviewed more than 100 cases to characterize common sources of confusion in ophthalmology care. The most common adverse events included wrong lens implants and wrong eye operations, and the authors predict that 85% would have been prevented with use of the Universal Protocol.