Massachusetts patient safety center report targets cataract surgery 'never events'
BOSTON >> A review of medical errors made during cataract surgeries in Massachusetts found cases where the wrong lens was implanted, anesthesia was incorrectly administered and procedures were performed on the wrong eye or wrong patient, prompting a call for new safety procedures.
Released Thursday by the Betsy Lehman Center for Patient Safety and Medical Error Reduction, the report calls for a "safety culture in which preventing patient harm is the top priority," along with a reassessment of anesthesia practices and standardized protocols around lenses and surgical markings.
The Betsy Lehman Center is a non-regulatory state agency that works to improve safety in health care. The report is the result of yearlong collaboration between the center, the state Department of Public Health, the Massachusetts Society of Eye Physicians and Surgeons, the Massachusetts Society of Anesthesiologists and trade associations for ambulatory surgery centers and hospitals.
In 2015, the Department of Public Health notified the Betsy Lehman Center of an "uptick in reports of Serious Reportable Events" — preventable errors causing patient harm — associated with cataract surgery, according to the report. The serious reportable events were characterized as "never events" that were entirely preventable.
The report says cataract surgery is the most common operation in the United States and among the safest procedures in medicine. More than 60,000 cataract surgeries were performed in Massachusetts in 2015.
"Because many individual cataract surgeons will never be personally involved in a serious harm event, they may not recognize the risk," the report said. "Yet the large numbers of cataract surgeries mean that even tiny rates of preventable error will result in large numbers of patients harmed unnecessarily."
The review examined five years of data and found the most frequent serious reportable event in cataract surgery was the implantation of a lens not intended for that patient. Errors in the administration of local anesthesia in some cases resulted in permanent vision loss.
From 2011 to 2015, 28 serious events were reported to the Department of Public Health, including 15 cases where the wrong lens was implanted, five where the wrong eye was anesthetized and five where nerve blocks caused loss of vision. Surgery was once performed on the wrong patient and once on the eye where the patient was not supposed to have surgery.
To prevent errors involving surgery with the wrong lens, wrong eye or wrong patient, the center's review recommended that medical facilities institute formal lens management policies and uniform policies for marking the operative eye.
Practitioners should also use the least invasive form of anesthesia appropriate for the case and engage patients in decisions about anesthesia and sedatives, according to the report.
The center is now working to develop a set of tools for providers to use to improve safety in cataract surgery.
"We also will be evaluating this initiative to understand how it can be repurposed to support meaningful, measurable change in other areas of health care - with the ultimate goal of eliminating preventable patient harm in Massachusetts," the report said.
The center is named for Betsy Lehman, a Boston Globe health reporter who died in 1994 due to a preventable medical error when she was being treated for breast cancer.