September 2016
Volume 57, Issue 12
Open Access
ARVO Annual Meeting Abstract  |   September 2016
Prevalence and Risk Factors of Wrong Site Surgery in Strabismus Surgeries
Author Affiliations & Notes
  • Donny W Suh
    Ophthalmology , University of Nebraska , Omaha, Nebraska, United States
  • Lauren Maloley
    Ophthalmology , University of Nebraska , Omaha, Nebraska, United States
  • Robin High
    Ophthalmology , University of Nebraska , Omaha, Nebraska, United States
  • Footnotes
    Commercial Relationships   Donny Suh, None; Lauren Maloley , None; Robin High, None
  • Footnotes
    Support  none
Investigative Ophthalmology & Visual Science September 2016, Vol.57, 2443. doi:
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      Donny W Suh, Lauren Maloley, Robin High; Prevalence and Risk Factors of Wrong Site Surgery in Strabismus Surgeries. Invest. Ophthalmol. Vis. Sci. 2016;57(12):2443.

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

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Purpose : Wrong-site surgery (WSS) continues to occur despite extensive efforts to understand the causes and to apply surgical safety protocols. WSS is defined as surgery on the wrong patient, the wrong site, the wrong procedure, or the wrong implant. These errors represent a preventable cause of morbidity and mortality in our healthcare system. A survey among pediatric ophthalmology surgeons was performed to assess a larger, more detailed set of factors that may contribute to WSS. We assessed whether the Universal Protocol is performed, mainly the pre-operative marking process and time-out procedures. We also evaluated the surgeons’ experience and the operating environment. This study was designed to identify the magnitude of WSS in strabismus surgery, to determine the risk factors leading to these errors, and to understand the effectiveness of the Universal Protocol.

Methods : 1050 Pediatric Ophthalmologists were contacted from June to July 2015 to complete an anonymous questionnaire. The survey was composed of 10 questions to determine the frequency of wrong site surgeries and to assess the risk factors contributing to errors. We evaluated how often the marking of the eyes was being performed and also how the marking of the surgical sites was made. In addition, the number of years of practice at that time of WSS, the number of surgical cases performed per year and the number of surgical sites utilized were analyzed.

Results : Of the 156 surgeons who responded to the survey, 88 had never performed a WSS operation, 54 surgeons performed one or more WSS errors, and 14 surgeons started the WSS but were able to rectify the problem before the surgery was completed.
We found that there is a decreased likelihood of error when any type of marking is performed, compared to not marking the eye (odds ratio, 0.39; p=0.06).
Also, the actual surgeon performing the “Time Out” process (instead of any other operating room staff) reduces the risk. In addition, surgeons with less than 15 years of practice were less likely to perform a WSS compared with those with greater than 15 years of practice.

Conclusions : We determined that WSS is not uncommon in the pediatric ophthalmology practice in the Universal Protocol era. We need to emphasize the need for continued evaluation and adjustment of the pre-operative and operative protocols to reduce the medical error, which are detrimental to our patients.

This is an abstract that was submitted for the 2016 ARVO Annual Meeting, held in Seattle, Wash., May 1-5, 2016.


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