Joshua Ong, Beth K Hansemann, Paul P Lee, Jennifer S Weizer
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Safety Outcomes Following Implementation of a Systematic Cataract Surgery Protocol at a Tertiary Referral Eye Center.
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.
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.
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