Eye Surgery Errors Avoidable

Most eye surgery errors could be avoided by following
standard procedures, such as marking the surgical site and taking a time-out
before incision.

A new study shows eye surgery errors are rare, occurring at a rate of about
69 errors per 1 million procedures.

The most common error was inserting the wrong lens implant, which happened
in 63% of cases reviewed for this study and usually happened because the lens
specifications were not checked properly before surgery.

The advent of laser eye surgery has made eye surgeries more common, but
researchers say little is known about the type of errors most commonly
associated with eye surgeries.

Medical mistakes and surgical errors have become a major concern in recent
years, and in 2004, new protocols were adopted by major medical organizations,
including the American Academy of Ophthalmology.

These safety procedures include verifying the patient's identity as well as
his or he procedure before surgery, marking the surgical site, and taking a
time-out immediately before incision.

Eye Surgery Errors Serious

The study, published in the Archives of Ophthalmology, involved 106
cases of eye surgery error reported to a major malpractice carrier and the New
York State Department of Health.

Researcher John W. Simon, MD, of Albany Medical College in New York, and
colleagues investigated how the error occurred, when and by whom it was
recognized, who was responsible, whether the patient was informed, and various
other aspects of how it happened.

The results showed most of the errors were caused by a breakdown in systems,
processes, and conditions that led people to make mistakes and 85% of the
errors could have been prevented if the safety protocols had been followed.

The most common error was implanting the wrong lens, which occurred in 67 of
the 106 cases, and was frequently caused by not checking the lens
specifications before surgery.

Other common eye surgery errors included:

• Injecting the wrong eye with anesthesia (13%)


• Operating on the wrong eye (14%)


• Eight cases involved the wrong patient or the wrong procedure.


• The wrong tissue was transplanted in two cases.

By Jennifer Warner
Reviewed by Louise Chang
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