Avoidance of serious medical errors in refractive surgery using a custom preoperative checklist

Abstract

Purpose: To implement and measure the effect of a surgical safety checklist on the prevention of serious medical errors (never-events).

Setting: Boston Eye Group, Boston, Massachusetts, USA.

Design: Retrospective cohort study.

Methods: A safety checklist incorporating 28 sources of error was designed and implemented in December 2011 at the Boston Eye Group's refractive surgical center. Consecutive patients who had primary or enhancement laser vision correction (LVC) between July 2009 and February 2014 were included in this study. Before that date, a general checklist fashioned around the World Health Organization time-out procedure was used. The latter subjects were recruited as controls. The perioperative characteristics of both groups were retrospectively compared.

Results: The study comprised 2951 consecutive patients who had primary or enhancement LVC between July 2009 and February 2014; of these, 1417 patients (2744 eyes) had LVC after the implementation of a presurgical safety checklist. The general checklist fashioned around the World Health Organization time-out procedure was used for 1534 patients (2969 eyes). Both groups were comparable in patient age. The most common surgical procedures were laser in situ keratomileusis (78%) and laser-assisted subepithelial keratectomy with mitomycin-C (16%). Although there were 2 (0.07%) serious errors in the prechecklist cohort, none occurred following implementation of the safety checklist protocol (P = .23). The medical errors involved wrong refractive aim in 1 patient and wrong person-wrong procedure-wrong aim in another.

Conclusions: Multiple potential sources of error exist in refractive surgery. The broad-scale implementation of a detailed presurgical safety checklist was helpful in minimizing and preventing serious errors (never-events) during LVC.

Financial disclosure: Drs. Shapiro and Urman are members of the Institute for Safety in Office-Based Surgery, a nonprofit organization whose aims are to implement safety checklists for office-based surgery. No author has a financial or proprietary interest in any material or method mentioned.