Advancing Patient Safety in Cataract Surgery: A Betsy Lehman Center Expert Panel Report

Report

Cataract surgery – now the most common surgery performed in the country – is also considered among the safest. Yet Massachusetts recently saw a surge in reports of errors associated with cataract surgery; so-called "never events" that are entirely preventable.

What can be learned from these events? Over the course of seven months, an expert panel of respected ophthalmologists, anesthesiologists, nurse managers, and patient representatives convened by the Betsy Lehman Center took a closer look. Four predominant risk areas were identified:

  1. Implantation of an intraocular lens not intended for the patient
  2. Surgery on the wrong patient (or wrong procedure on the patient)
  3. Surgery or anesthesia on the wrong eye
  4. Other injuries related to anesthesia

The goal of the panel's work was to learn as much as possible from available data and literature, increase awareness of common safety risks, and trigger the implementation of evidence-based best practices to reduce the risk of patient harm at all Massachusetts cataract surgery facilities.

This initiative was unique in a number of ways:

  • Several professional and trade associations, three state agencies, researchers, and individual practitioners shared information and worked together to better understand risks to the safety of cataract surgery patients.
  • Medical personnel at four of the facilities that experienced a recent serious adverse event spoke candidly with the Betsy Lehman Center about their experiences.
  • The consumer voice was at the table, with two patient representatives serving on the panel alongside medical professionals.

Health care providers often implement process improvements in the aftermath of a significant adverse event. The panel's report contains a call to action for all who participate in the delivery of cataract surgery to put themselves in the shoes of their peers who once thought, "It will never happen to me."

This initiative encourages surgeons, anesthesiologists, nurses, technicians, and administrators to scrutinize their current practices and implement steps to prevent events like the ones reported in Massachusetts from happening again.

The panel:

  • Nicholas Argy, MD, JD, Adjunct Assistant Professor, Boston University School of Public Health and member of the Board of Registration in Medicine's Quality and Patient Safety Committee
  • Patrice Baril, MS, RN, Nurse Manager, Surgical Services, Lahey Medical Center Peabody
  • Joseph Bayes, MD, Assistant Professor of Anesthesia, Harvard Medical School and Massachusetts Eye and Ear Infirmary, and member of the Massachusetts Medical Society's Committee on the Quality of Medical Practice
  • Michael Chang, MD, Chair, Massachusetts Society of Eye Physicians and Surgeons' Clinical Quality and Ethics Committee
  • Teresa Chen, MD, Associate Professor, Ophthalmology, Harvard Medical School and Chief Quality Officer for Ophthalmology, Massachusetts Eye and Ear Infirmary
  • Stefan Ianchulev, MD, Director of Quality Assurance and Improvement, Department of Anesthesiology, Tufts Medical Center
  • Michael Morley, MD, ScM, Ophthalmic Consultants of Boston and Assistant Clinical Professor of Ophthalmology, Harvard Medical School
  • Katie Murphy, RN, Administrator, Plymouth Laser & Surgical Center
  • Karen Nanji, MD, MPH, Assistant Professor of Anesthesia, Massachusetts General Hospital, Department of Anesthesia, Critical Care and Pain Medicine
  • Natalie Nathan, Patient and Family Advisory Council Member, Beth Israel Deaconess Medical Center
  • Spiro Spanakis, DO, Assistant Professor of Anesthesiology and Pediatrics, University of Massachusetts Medical School and Director of Quality and Safety, UMASS Memorial Medical Center, Department of Anesthesiology
  • Nicola Truppin, JD, Patient and Family Advisory Council Member, Beth Israel Deaconess Medical Center