Process assessment is key to prevention of certain ophthalmology events
- Collection:
- Health Policy and Services Research
- Series Title(s):
- Pennsylvania patient safety advisory
- Author(s):
- Magee, Mary C., author
- Contributor(s):
- Pennsylvania. Patient Safety Authority, issuing body. ECRI (Organization), issuing body. Institute for Safe Medication Practices, issuing body.
- Publication:
- [Harrisburg, Pennsylvania] : Pennsylvania Patient Safety Authority, September 2016
- Language(s):
- English
- Format:
- Text
- Subject(s):
- Cataract Extraction -- adverse effects Lens Implantation, Intraocular -- adverse effects Medical Errors -- prevention & control Medical Errors -- statistics & numerical data Process Assessment (Health Care) Forecasting Medical Errors -- trends Medication Errors -- statistics & numerical data Patient safety Risk Management Humans Massachusetts Pennsylvania United States
- Genre(s):
- Technical Report
- Abstract:
- An estimated 24 million Americans have cataracts, making cataract removal and intraocular lens insertion one of the most common surgeries performed in the United States. Cataract surgery is safe, and serious injuries rarely occur. So when an increase in reports of Serious Events related to cataract procedures occurred in one year in Massachusetts, the Betsy Lehman Center for Patient Safety responded. The Center collaborated with a number of state and professional agencies, formed an expert panel, and consulted with the Pennsylvania Patient Safety Authority. The Authority found that from July 1, 2004, through June 30, 2015, Pennsylvania acute care facilities reported 4,307 events related to cataract procedures and 23 wrong-site anesthesia eye injections. Since July 2004, reporting of intraocular lens procedure-related events, which includes near misses and good catches, has steadily increased while the number of incorrect intraocular lens implant events has decreased. The Authority estimates the incidence of cataract-related surgical confusions in Pennsylvania at 61.8 per 1 million procedures for the July 1, 2004, through June 30, 2015, period. In response to a rising trend of intraocular lens-related reports, increased vigilance towards prevention is necessary. Active participation by engaged staff in executing the Universal Protocol--including engaging the patient--and use of an ophthalmology-specific perioperative checklist remain the recommended best practices to prevent wrong eye identification, incorrect lens implantation, and wrong-site anesthesia eye injections.
- Copyright:
- Reproduced with permission of the copyright holder. Further use of the material is subject to CC BY-NC-ND license. (More information)
- Extent:
- 1 online resource (1 PDF file (pages 92-99))
- Illustrations:
- Illustrations
- NLM Unique ID:
- 101693070 (See catalog record)
- Permanent Link:
- http://resource.nlm.nih.gov/101693070