Physician Resources Home arrow Medical News arrow Surgical errors rare but serious in ophthalmic procedures
Surgical errors rare but serious in ophthalmic procedures
Written by Medical News Feed   

CHICAGO—Surgical confusions—for instance, operations involving the wrong site, the wrong patient or the wrong procedure—occur infrequently in eye surgery procedures, according to a report in the November issue of Archives of Ophthalmology, one of the JAMA/Archives journals. Although most surgical confusions cause little or no permanent injury, they may involve serious consequences for the patient, physician and profession, yet could often be prevented.

Discuss this article on the forums. (0 posts)



“Surgical confusions (i.e., wrong patient, wrong site, wrong procedure) are an increasingly recognized cause of morbidity, recently representing the most common category of reportable medical error,” the authors write as background information in the article. “In July 2004, the Joint Commission on Accreditation of Healthcare Organizations, in concert with many professional organizations, including the American Academy of Ophthalmology, promulgated the Universal Protocol in an effort to prevent such confusions in all surgical procedures. This protocol includes consistent preoperative verification, site marking and a time-out immediately before incision.”

John W. Simon, M.D., of the Lions Eye Institute, Albany Medical College, N.Y., and colleagues retrospectively analyzed 106 cases of surgical confusions involving eye operations that occurred between 1982 and 2005. This included 42 cases from the Ophthalmic Mutual Insurance Company and 64 from the New York State Health Department.

Their analysis found that:

  • The most common confusion was wrong lens implants, which occurred in 67 of 106 cases (63 percent) and most often happened because lens specifications were not checked properly before implantation.
  • The wrong eye was injected with anesthesia in 14 cases (13 percent) and operated on in 15 cases (14 percent).
  • In eight cases, confusions involved the wrong patient or the wrong procedure.
  • The wrong tissue was transplanted in two cases.
  • Confusions involving the wrong implant or transplant more often caused severe injuries than those involving the wrong eye, patient or procedure.
  • The Universal Protocol, if implemented, would have prevented 85 percent of the confusions.


The authors estimate that these data suggest a rate of 69 surgical confusions for every 1 million eye operations.

“The causes of these confusions were faulty systems, processes and conditions that led people to make mistakes, more often than an individual’s recklessness,” the authors write. “The traditional response to medical error, ‘blame, shame and train,’ therefore misses the point. Humiliating or otherwise disciplining caregivers tends to perpetuate a culture of secrecy that impedes effective root-cause analysis and future improvement. A more enlightened approach is entirely non-punitive, drawing on methods of crew resource management adapted from the airlines and the defense department.”
(Arch Ophthalmol. 2007;125(11):1515-1522.

Editor's Note: This study was supported in part by a grant from the Sight Society of Northeastern New York, Inc. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

For more information, contact JAMA/Archives media relations at 312/464-JAMA (5262) or e-mail mediarelations{at} .

Discuss this article on the forums. (0 posts)

< Prev   Next >

Common Diseases

Swine Flu - Updates and information on H1N1 2009 (AKA Swine Influenza) pandemic.

Ankylosing spondylitis - Current protocols for diagnosis and treatment options.

Wegener granulomatosis - Autoimmune etiology and clinical course.

Diabetes - disease and management information, including diagnosis, typical treatment plans and diabetes supplies.


Medical Careers

The US medical jobs market has stayed hot for health care providers. Whether you believe that a provider shortage is in the offing or that the ratio of physicians-to-patients is too high, physician jobs and nursing jobs abound.

A wide variety of medical jobs can be found in the netdoc health care job listings. Particular strengths include permanent and locum tenens physician jobs, nursing jobs across the US, and radiology positions.

Other resources include physician salary information, medical career guidance, and the ability to post physician jobs.


When hiring your medical practice office manager, what was the most important consideration?
Copyright 2005 - 2020 Medical Resource Group, LLC. All rights reserved.