Medical errors and patient safety in Ophthalmology

González-López, J.J.; Hernández-Martínez, P.; Muñoz-Negrete, F.J.

doi:10.1016/j.oftale.2017.03.011

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Some of these, like the simultaneous appearance of optical coherence tomography imaging and antiangiogenics biological medicaments, have allowed us to treat a large number of patients who in the past were untreatable. In addition, breakthroughs in phacoemulsification and vitrectomy have enabled safer and faster surgeries. This, together with the aging of Spain's population pyramid, has multiplied the number of patients receiving medical and surgical treatment in our practices. The high volume of patients requires the execution of numerous procedures per day, thus increasing the risk of medical error.Accordingly, it must be remembered that the safety of our patients is an undeniable responsibility of our medical practice. From the viewpoint of bioethics, the absence of maleficence is one of the first level principles.<a class="elsevierStyleCrossRef" href="#bib0055">1</a> And from the viewpoint of healthcare quality, patient safety is included together with efficacy and satisfaction among the first level indicators.<a class="elsevierStyleCrossRef" href="#bib0060">2</a> In addition, overseeing patient safety is an important prevention approach that can prevent avoidable suffering and treatment. Recently, the American Ophthalmology Academy<a class="elsevierStyleCrossRef" href="#bib0065">3</a> and the International Council of Ophthalmology<a class="elsevierStyleCrossRef" href="#bib0070">4</a> have made a call for the prevention of errors in ophthalmological surgery.A 2007 American series comprising 106 cases of surgical errors in cataract surgery reported that the most frequent errors were implanting the wrong intraocular lens (63%), operating the wrong eye (14%) and operating the wrong patient/performing the wrong procedure (8%).<a class="elsevierStyleCrossRef" href="#bib0075">5</a> Another series in Hong Kong 2015 reported that operating the wrong side accounted for 41% of errors, whereas performing the wrong procedure accounted for 17%.<a class="elsevierStyleCrossRef" href="#bib0080">6</a>At presence, intravitreal injections are the most frequent surgical procedure, exceeding phacoemulsification in number of interventions. The high number of procedures carried out per day considerably increases the risk of making mistakes. A British study on 166 errors between 2003 and 2010 reported that the injection of the wrong medicament accounted for 16% of errors and that 10% were on the wrong eyes or patients.<a class="elsevierStyleCrossRef" href="#bib0085">7</a>It is necessary for daily clinic practice to further develop a safety culture to allow us to prevent avoidable adverse events and to minimize the incidence of unavoidable ones.The first step in the development of a safety culture in our practice is to understand why it is necessary to study adverse events in healthcare. It is not about singling out guilty parties but to understand why they occur. An adverse event is defined as an event related to health care that has negative consequences for patients. An adverse event can be avoidable (for instance, medication errors or intervening the wrong eye) or unavoidable (e.g., post-surgery endophthalmitis). If we are able to identify the causes that give rise to adverse events, we will be able to modify them to prevent avoidable events and diminish the frequency of unavoidable events.The next step is to oversee the adverse events that occur in the department, to which end it is very useful to define a listing of sentinel events. In general, these are critical events, i.e., sufficiently severe adverse events so as to produce severe consequences in a patient (death, disability, hospital admittance or surgery) that are not derived from the primary disease. Various organizations have created specific sentinel event listings for ophthalmology, like the Royal College of Ophthalmologists of the United Kingdom<a class="elsevierStyleCrossRef" href="#bib0090">8</a> or the hospital authority of Hong Kong.<a class="elsevierStyleCrossRef" href="#bib0080">6</a>The third step is to report sentinel events when they take place or, even better, when they are detected before damage is done (what is known as a near-miss). All the members of the team, including nonmedical staff (nurses, optometrists, etc.) must be given training on patient safety and be aware of the importance of reporting sentinel events and developing the ability of reporting these events to the patient safety chief.Lastly, the causes of adverse events must be studied to develop methods to prevent them. One of the methods that has demonstrated to be highly efficient to prevent surgical errors is the universal protocol<a class="elsevierStyleCrossRef" href="#bib0095">9</a> that comprises 2 essential parts:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">-Presurgery verification: before entering the surgery, a check must be made to verify that all documents are available. In the case of any discrepancy, it is possible to discuss it with the patient. When confirmation is requested from the patient, it is important to make open-ended questions of the type “could you tell me your name and date of birth?”. Patients with dementia and other vulnerabilities can respond affirmatively to closed questions even when they are not true. It is necessary to check:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0010">•Patient identity (asking more data in addition to name and surname, such as date of birth or address).</li><li class="elsevierStyleListItem" id="lsti0015">•Presence of clinic record.</li><li class="elsevierStyleListItem" id="lsti0020">•Signed and valid informed consent for the procedure to be carried out.</li><li class="elsevierStyleListItem" id="lsti0025">•Markings on the side to be operated. Once again, if the patient is hasta question, it should not be a closed question.</li><li class="elsevierStyleListItem" id="lsti0030">•Allergies to medicaments.</li><li class="elsevierStyleListItem" id="lsti0035">•Use of anticoagulants/antiplatelet agents.</li><li class="elsevierStyleListItem" id="lsti0040">•Implant or medicament to be required during surgery.</li></ul></li><li class="elsevierStyleListItem" id="lsti0045">-Time-out: A break in the surgery room before beginning the procedure. This involves the positive confirmation of data relating to the procedure together with active listening of all surgery team members. The procedure must not begin before all doubts have been resolved. The following must be checked:<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0050">•Patient identity.</li><li class="elsevierStyleListItem" id="lsti0055">•Allergies to medicaments.</li><li class="elsevierStyleListItem" id="lsti0060">•Use of anticoagulants/antiplatelet agents.</li><li class="elsevierStyleListItem" id="lsti0065">•Correct surgical procedure.</li><li class="elsevierStyleListItem" id="lsti0070">•Correct informed consent.</li><li class="elsevierStyleListItem" id="lsti0075">•Correct side.</li><li class="elsevierStyleListItem" id="lsti0080">•Correct implant (or medicament in the case of intravitreal injections).</li></ul></li></ul>In practice, timeout takes less than one minute per patient. In addition to the above 2 steps, it is advisable to add a briefing before beginning with the surgical list, where the head surgeon explains to the team the details of the operations to be carried out in the course of the day (types of anesthesia, allergies, risk of complications) to make sure that all the necessary material will be available, as well as a debriefing at the end of the day to discuss issues that may have arisen to propose solutions to avoid re-occurrences in the future.To end, we must remember that, despite all our efforts, medical errors will continue to occur because errors are inherent to human nature.<a class="elsevierStyleCrossRef" href="#bib0100">10</a> Accordingly, it is also up to the physician to manage them when they arise. In these cases, patients feel particularly vulnerable and it is necessary to manage emotions, exploring what the patient knows and what he wants to know about the events, apologize for necessary, showing compassion and assertiveness when discussing prognosis and support in the course of the process to be followed." "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: González-López JJ, Hernández-Martínez P, Muñoz-Negrete FJ. El error médico y la seguridad del paciente en Oftalmología. Arch Soc Esp Oftalmol. 2017;92:299–301." ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:1 [ "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "T.L. Beauchamp" 1 => "J.F. Childress" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:5 [ "edicion" => "7th ed." 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ISSN: 2173-5794
e-ISSN: 1989-7286

Archivos de la Sociedad Española de Oftalmología is the official journal of the Ophthalmology Society of Spain, that has over 4,000 members. It gives priority to the publication of basic, translational and clinic research including reviews, original articles, short communications, editorials, letters to the editor and clinic practice guides related to Ophthalmology and its subspecialties. A small section of the journal is reserved for the most relevant papers presented at the annual Congress of the Society. All manuscripts considered for publication are reviewed by expert examiner peers (double blind). The journal is published monthly and even though its official language is Spanish all articles are translated into English to increase the dissemination of scientific information. At present, Archivos is the only Spanish language Ophthalmology journal indexed in PubMed/MEDLINE in addition to other prestigious international databases such as Scopus.

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Vol. 92. Issue 7.