Errors in the OR

November 25, 2009

Poor communication is leading to a high number of mistakes in ophthalmic surgeries, according to a study published in the November issue of Archives of Surgery.

Poor communication is leading to a high number of mistakes in ophthalmic surgeries, according to a study published in the November issue of Archives of Surgery.

The study of surgery-related adverse events at Veterans Health Administration Medical Centres in the US looked at 342 reported events, including 212 adverse events, where a surgical procedure was performed unnecessarily. Of these adverse events, 45 were associated with ophthalmology, joint highest along with invasive radiology. The researchers calculated that 1.8 in every 10,000 cases feature an adverse event, commonly a lens mix up, which occurred in 48.9% of these events.

Communication was identified as the leading cause of these events, taking the blame in 21%. The authors suggest that earlier communication based on crew resource management would be beneficial in preventing some of these events.

The researchers acknowledged that not all mistakes are reported and that the frequency of reported events in ophthalmology could reflect a quality assurance-attentive department head. The authors suggest that a standardized system would allow for more reliable data capturing in this area.