May 2004
Volume 45, Issue 13
ARVO Annual Meeting Abstract  |   May 2004
TITLE: An observational study of 'near misses' in a cataract theatre.
Author Affiliations & Notes
  • K. Mandal
    Ophthalmology, Sunderland Eye Infirmary, Sunderland, United Kingdom
  • S. Fraser
    Ophthalmology, Sunderland Eye Infirmary, Sunderland, United Kingdom
  • Footnotes
    Commercial Relationships  K. Mandal, None; S. Fraser, None.
  • Footnotes
    Support  none
Investigative Ophthalmology & Visual Science May 2004, Vol.45, 1405. doi:
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      K. Mandal, S. Fraser; TITLE: An observational study of 'near misses' in a cataract theatre. . Invest. Ophthalmol. Vis. Sci. 2004;45(13):1405.

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      © ARVO (1962-2015); The Authors (2016-present)

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Abstract: : Purpose: In most hospitals, adverse incidents are reported using a central adverse incident reporting system. However, the more frequently occurring near misses, are not usually recorded – in many specialties they are not even defined. The aim of this study was to look at what experienced ophthalmic nurses, in a cataract theatre, would consider to be a near miss and how often these events occurred. Method: A prospective observational study. The study was performed over a period of 11 consecutive weeks and 504 cataract operations were chosen at random during this period. The nurse who accompanied the patient throughout the operation was asked to record whether there was, in her/his opinion, any deviations form the ‘norm’ occurring peri–operatively. The nurses were not given any guidance about which events to consider but were free to record those that they considered to be significant. Results: 14% of forms returned were ‘positive’ (i.e. an event had occurred that the nurse had felt was potentially significant). The majority of the described events occurred during the operation itself –with 27% of all the positive responses related to problems with instruments. Of the non–operative deviations, 13% of all the positive responses noted a significant delay in starting the operation. Conclusion: This study is the first to look at near misses in a cataract theatre. More than 1 in 10 operations were deemed to have had an event that deviated sufficiently from the norm for the nurse to record. The commonest area for this deviation was instrument problems during the surgery, but possible near misses were seen to occur during all parts of the process from the patient arriving in theatre to them leaving. Further work is now required to define near misses and to attempt to calculate their incidence. It is only by doing this that we can put in place mechanisms to try to reduce them.

Keywords: cataract 

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