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ES Loft, DM Marcus; Wrong-Site Eye Surgery . Invest. Ophthalmol. Vis. Sci. 2002;43(13):3501.
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Purpose: To review the literature, contributing factors, prevention recommendations, and medical legal data regarding wrong-site eye surgery. Methods: We preformed a computer literature search assessing the published ophthalmic literature pertaining to wrong-site eye surgery. We reviewed medical and nursing society internet web sites and journals for materials and recommendations for prevention of wrong-site surgery. We obtained malpractice and liability data through personal communication with physican insurer consultants, and with the review of physician insurer and professional liability internet web sites. Results: To the best of our knowledge, wrong-site eye surgery has not been discussed in the published ophthalmic literature since 1947. Between 1995-2001, 10.4% of 1294 sentinel events reviewed by the Joint Commission on Accreditation of Healthcare Organizations were wrong site surgeries. The worlds largest malpractice database indicates 928 closed claims from wrong-site surgery from 1985-1997. Nineteen of these 928 claims occured in ophthalmology. Seventy-nine percent of wrong-site ophthalmology claims resulted in an indemnity payment, whereas 70-77% of overall closed ophthalmology claims result in no payment. Orthopedic surgery is the discipline with the highest number of wrong site surgery malpractice claims. Accordingly, the American Academy of Orthopedic Surgeons created a campaign to increase awareness of prevention strategies. The American Academy of Ophthalmology internet web site has recently posted their first patient safety bulletin, entitled, "Eliminating Wrong Site Surgery". We will discuss the currently accepted contributing factors and prevention strategies suggested by these societies. Conclusion: Wrong-site eye surgery is rarely discussed in the ophthalmic literature. Implications of wrong-site eye surgery include high likelihood of indemnity payment, as well as deleterious effects to a patient's health and vision. These events can be avoided by implementation of prevention strategies in all surgical facilities.
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