Reducing wrong intraocular lens implants in cataract surgery.
Int J Health Care Qual Assur
; 30(6): 492-505, 2017 Jul 10.
Article
em En
| MEDLINE
| ID: mdl-28714828
ABSTRACT
Purpose Wrong lens implants have been associated with the highest frequency of medical errors in cataract surgery. The purpose of this paper is to explore the use of the Systems Engineering Initiative for Patient Safety (SEIPS) framework to sustainably reduce wrong intraocular lens (IOL) implants in cataract surgery. Design/methodology/approach In this mixed-methods study, the SEIPS framework was used to analyse a series of (near) misses of IOL implants in a national tertiary specialty hospital in Singapore. A series of interventions was developed and applied in the case hospital. Risk assessment audits were done before the interventions (2012; n=6,111 surgeries), during its implementation ( n=7,475) and in the two years post-interventions (2013-2015; n=39,390) to compare the wrong IOL-rates. Findings Although the absolute number of incidents was low, the incident rate decreased from 4.91 before to 2.54 per 10,000 cases after. Near miss IOL error decreased from 5.89 before to 3.55 per 1,000 cases after. The number of days between two IOL incidents increased from 35 to an initial peak of 385 before stabilizing on 56. The large variety of available IOL types and vendors was found as the main root cause of wrong implants that required reoperation. Practical implications The SEIPS framework seems to be helpful to assess components involved and develop sustainable quality and safety interventions that intervene at different levels of the system. Originality/value The SEIPS model is supportive to address differences between person and system root causes comprehensively and thereby foster quality and patient safety culture.
Palavras-chave
Texto completo:
1
Base de dados:
MEDLINE
Assunto principal:
Gestão de Riscos
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Extração de Catarata
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Gestão da Segurança
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Erros Médicos
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Melhoria de Qualidade
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Lentes Intraoculares
Tipo de estudo:
Etiology_studies
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Prognostic_studies
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Risk_factors_studies
Limite:
Humans
País como assunto:
Asia
Idioma:
En
Ano de publicação:
2017
Tipo de documento:
Article