Safety Outcomes Following Implementation of a Systematic Cataract Surgery Protocol at a Tertiary Referral Eye Center.

IF 1.7 3区医学 Q3 HEALTH CARE SCIENCES & SERVICES

Journal of Patient Safety Pub Date : 2025-06-09 DOI:10.1097/PTS.0000000000001376

Joshua Ong, Beth K Hansemann, Paul P Lee, Jennifer S Weizer

{"title":"Safety Outcomes Following Implementation of a Systematic Cataract Surgery Protocol at a Tertiary Referral Eye Center.","authors":"Joshua Ong, Beth K Hansemann, Paul P Lee, Jennifer S Weizer","doi":"10.1097/PTS.0000000000001376","DOIUrl":null,"url":null,"abstract":"Purpose: To evaluate the longitudinal safety outcomes of incorrect intraocular lens (IOL) implantation using a standardized cataract surgery operating standard operating procedure (SOP) devised at a tertiary referral eye center. This evaluation represents a critical but underrepresented topic in ophthalmic literature.Methods: This was a quality improvement, retrospective analysis, and description of the Healthcare Failure Mode Effect and Analysis (HFMEA) and resultant SOP implemented in 2018 following incorrect IOL events. Analysis of subsequent safety events following implementation of the SOP and modifications/reassessments performed was analyzed. The main outcome measures were processes identified in the HFMEA and incorrect IOL safety events occurring following implementation of the SOP.Results: The HFMEA identified 170 processes/subprocesses steps, 177 potential failure modes, and 75 potential failure mode causes. Twenty-nine system vulnerabilities were identified through analysis of the failure mode causes. From 2018 to 2023, 8 additional incorrect IOL safety events occurred, which led to subsequent revisions of the SOP.Conclusion: Continuous reassessment of standardized protocols for cataract surgery is critical to ensure patient safety.","PeriodicalId":48901,"journal":{"name":"Journal of Patient Safety","volume":" ","pages":""},"PeriodicalIF":1.7000,"publicationDate":"2025-06-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":"0","resultStr":null,"platform":"Semanticscholar","paperid":null,"PeriodicalName":"Journal of Patient Safety","FirstCategoryId":"3","ListUrlMain":"https://doi.org/10.1097/PTS.0000000000001376","RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"","PubModel":"","JCR":"Q3","JCRName":"HEALTH CARE SCIENCES & SERVICES","Score":null,"Total":0}

引用次数: 0

Abstract

Purpose: To evaluate the longitudinal safety outcomes of incorrect intraocular lens (IOL) implantation using a standardized cataract surgery operating standard operating procedure (SOP) devised at a tertiary referral eye center. This evaluation represents a critical but underrepresented topic in ophthalmic literature.

Methods: This was a quality improvement, retrospective analysis, and description of the Healthcare Failure Mode Effect and Analysis (HFMEA) and resultant SOP implemented in 2018 following incorrect IOL events. Analysis of subsequent safety events following implementation of the SOP and modifications/reassessments performed was analyzed. The main outcome measures were processes identified in the HFMEA and incorrect IOL safety events occurring following implementation of the SOP.

Results: The HFMEA identified 170 processes/subprocesses steps, 177 potential failure modes, and 75 potential failure mode causes. Twenty-nine system vulnerabilities were identified through analysis of the failure mode causes. From 2018 to 2023, 8 additional incorrect IOL safety events occurred, which led to subsequent revisions of the SOP.

Conclusion: Continuous reassessment of standardized protocols for cataract surgery is critical to ensure patient safety.

查看原文本刊更多论文

三级转诊眼科中心系统白内障手术方案实施后的安全性结果。

目的：评价在三级转诊眼科中心采用标准化白内障手术操作标准操作程序（SOP）进行不正确人工晶状体植入术的纵向安全性。这个评价代表了眼科文献中一个关键但代表性不足的话题。方法：这是2018年错误IOL事件后实施的医疗失败模式影响和分析（HFMEA）和由此产生的SOP的质量改进、回顾性分析和描述。分析了SOP实施后的后续安全事件，并进行了修改/重新评估。主要结果测量是HFMEA中确定的过程和执行SOP后发生的不正确的IOL安全事件。结果：HFMEA识别了170个过程/子过程步骤、177个潜在失效模式和75个潜在失效模式原因。通过故障模式原因分析，确定了29个系统漏洞。从2018年到2023年，又发生了8起不正确的人工晶状体安全事件，这导致了SOP的后续修订。结论：持续重新评估白内障手术的标准化方案对确保患者安全至关重要。

本文章由计算机程序翻译，如有差异，请以英文原文为准。

求助全文

约1分钟内获得全文求助全文

来源期刊

Journal of Patient Safety HEALTH CARE SCIENCES & SERVICES-

CiteScore

4.60

自引率

13.60%

发文量

302

期刊介绍： Journal of Patient Safety (ISSN 1549-8417; online ISSN 1549-8425) is dedicated to presenting research advances and field applications in every area of patient safety. While Journal of Patient Safety has a research emphasis, it also publishes articles describing near-miss opportunities, system modifications that are barriers to error, and the impact of regulatory changes on healthcare delivery. This mix of research and real-world findings makes Journal of Patient Safety a valuable resource across the breadth of health professions and from bench to bedside.