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 Table of Contents  
Year : 2022  |  Volume : 34  |  Issue : 2  |  Page : 94-97

Ensuring patient safety in eye care

Aravind Eye Hospital, Madurai, Tamil Nadu, India

Date of Submission04-May-2022
Date of Decision09-May-2022
Date of Acceptance15-May-2022
Date of Web Publication30-Aug-2022

Correspondence Address:
Dr. R D Ravindran
Aravind Eye Hospital, Madurai, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/kjo.kjo_61_22

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Due to the frequent and rapid development of new drugs, changes in treatment protocols and patient care delivery systems including technology, patient care in health care settings is becoming increasingly complex. However, there is a greater expectation from the patient and the community regarding the quality of patient care, outcomes, and timely delivery. These create stressful situations, making the care process prone to errors, resulting in unsafe incidents. Common errors in ophthalmology include incorrect procedures, identification errors, technical errors, medical or diagnostic errors, and documentation errors. Hence, there is a dire need to create comprehensive methods to support error-free patient care. These include standardization, developing safety protocols, safety checklists, training the staff, creating a platform for reporting, performing a root-cause analysis, monitoring, and periodical meetings to improve and continue the process. Providing a dignified, non-punitive approach with a well-defined system is paramount for ensuring patient safety in eye care.

Keywords: Checklists, eye care, patient safety

How to cite this article:
Ravindran R D. Ensuring patient safety in eye care. Kerala J Ophthalmol 2022;34:94-7

How to cite this URL:
Ravindran R D. Ensuring patient safety in eye care. Kerala J Ophthalmol [serial online] 2022 [cited 2023 Feb 2];34:94-7. Available from: http://www.kjophthal.com/text.asp?2022/34/2/94/355038

  “First do no harm” Top

The guiding principle of patient care. With the recent advancements in the development of new drugs, change in treatment protocols, care delivery systems, and technology, patient care in healthcare settings is becoming complex. As a result of the increasing complexity, the number of people involved in delivering the care also has been increasing. At the same time, there is a greater expectation from the patients and community on the quality of patient care, outcomes, and also timely delivery. The complexity of the care processes, the expectations of the patients, and the involvement of multiple care providers make the care process error-prone, resulting in unsafe incidents. This commonly relates to medication errors, lack of coordinated care, and hospital-acquired infections in general healthcare settings. At the global level, the World Health Organization (WHO) and other international agencies such as Joint Commission, Patient Safety Movement Foundation, etc., highlight the importance of patient safety in health care and urge the national governments to develop strategic plans for the next decade to ensure safety.[1] Recently, the World Health Assembly (WHA) has adopted a resolution (WHA 72.6) on patient safety to make it a global priority, and this endorsed the establishment of World Patient Safety Day to be observed annually on September 17.[2]

In ophthalmology as well, there is an explosion of new technology both in the surgical techniques as well as in surgical supplies used in surgery. Recent advancements have resulted in the introduction of a number of new intraocular lenses to enhance the quality of vision for patients undergoing cataract surgery, newer intravitreal drugs to treat vascular diseases of the retina, and novel laser technologies to surgically correct refractive errors. In addition, there are also several new pieces of equipment for ensuring a comprehensive clinical assessment that facilitates accurate clinical diagnosis and also to aid in the precision of the surgery performed. Comprehensive eye examination requires several measurements and involves a coordinated effort between ophthalmologists, refractionists, and other allied health personnel. As a result, now, we have more than one modality of treatment for most eye diseases, impacting the delivery of proposed surgical or medical care. All these in turn increase the probability of occurrences of errors in measurement, transcription of measurements, identification of the patient or the eye, or using a wrong implant or intravitreal drug in eye care settings, which may result in harm or poor outcomes to the patients. Whereas both the patients and caregivers are focused on providing good clinical outcomes, they are not aware of the dangers posed by the current complexity in care delivery resulting in safety errors.

The major focus in patient safety in general healthcare is on medication safety and prevention of hospital-acquired infections,[3] whereas it is mostly surgery-related errors in ophthalmology. According to a recently published follow-up study[4] (conducted at the US Veterans Health Administration medical centers) on the assessment of incorrect surgical procedures within and outside the operating room, the highest number of reported errors or adverse events occurred in ophthalmology (72), followed by dentistry (30) and anesthesiology (28). However, when examining in-Operating Room (OR) reported adverse event rates by specialty, dentistry had 1.54, neurosurgery had 1.53, and ophthalmology had 1.06 reported in-OR adverse events per 10,000 cases. Common errors in ophthalmology include a broad range. Some of them are as follows:

  • Incorrect procedures: Wrong eye surgery, wrong eye anesthetic block, and wrong lens power or design-implanted
  • Identification errors: Patients presenting with the same name and those mistakenly chosen for wrong procedures
  • Technical errors: Wrong refraction, wrong mode selection in equipment, wrong formula chosen for calculation, and wrong measurement done
  • Medical or diagnostic errors: Failure to diagnose the conditions leading to visual loss or postoperative infections
  • Documentation errors: Transcription errors, documenting the findings in the wrong eye, wrong spectacle prescription, and wrong drug prescription

Apart from these errors, patient fall and patient morbidity and mortality due to uncontrolled systemic diseases are also becoming increasingly common. Failure in detecting the conditions leading to such errors put the systems under great stress.

In a study by Simon et al.,[5] 62 cases of safety errors were reported from 900,000 eye operations performed in New York state between 2001 and 2005, which works out an incidence of one major safety error per 14,493 procedures.

Evidence from these studies also suggests that more than half of the errors could have been prevented. Prevention of errors can happen when we understand that these errors happen due to several factors ranging from technology to communication. Thus, ensuring patient safety during the care delivery process in the eye requires hospital-wide effort, involving a wide range of actions to mitigate all factors leading to errors.

Patient safety is fundamental for delivering quality care. Having said that, it is also important to understand that “to err is human” and expecting zero errors from healthcare providers who have to work in an increasingly complex, ever-changing, and stressful environments may be impractical.

Errors in healthcare can be acute or latent.[6] Acute errors refer to errors that are apparent and happen at the frontline and are easily noticed because they are committed by people working at the final point of care delivery and there are no contributory factors. The cause for the error is not carried throughout the process and is unpredictable. These acute errors often happen due to human factors related to fatigue, lack of sleep, etc. This shows that safety is a dynamic and not a static situation, and we need to have processes to address these human factors as well.

In contrast, latent errors caused by latent conditions refer to less apparent system-level failures that contribute to the occurrence of safety errors. This includes contributing factors such as lack of policy, process, inappropriate technology, etc. The latent errors are long-lived and occur as a result of unsafe practices or lack of adherence to safety protocols or not having safety protocols. The unsafe culture developed over a period of time lies dormant before combining with other factors or active failures to breach a system's safety defenses. These latent conditions can be identified and removed before they cause an adverse event. However, if systems are not monitored or audited, then the latent conditions may become an accepted and embedded part of the culture.[2]

Although the errors do not result in conditions as devastating as what happens in the other healthcare disciplines, in ophthalmology also, adverse events happen all time, affecting the patient physically, emotionally, and/or financially. In the recent evolvement of patient safety, the mental shift from blaming an individual for causing harm to the systems in which they work has made organizations look for reasons beyond human. The harsh reality of today's healthcare environment is that the systems that support patient care are becoming complex and error-prone, and most organizations lack a comprehensive method for making them less so. Hence, there is a dire need to be proactive than reactive.

Reducing eye surgery adverse events has been a challenge. The cases are short, the time pressure is high, and there are multiple steps in the process from measuring the needed intraocular lens power in the clinic to implanting a non-expired correct lens in the OR.[4] To make an eye organization safer and sustain, the organization needs to follow the following:

  • Standardization: Standardizing and improving the work processes reduces the risk of errors. In the process, it is vital to identify the process owners who are responsible for creating or updating the standard operating procedures and continue to do risk assessments.
  • Developing safety protocols and safety checklists: Checklists have proven to nearly double the likelihood that patients will receive proven standards of care[7] and be the best way to reduce safety errors and improve patient safety. Checklists can be prepared for every invasive procedure, based on the WHO Surgical Safety Checklist [Figure 1] and customizing it to the organization by understanding where things can go wrong in their current setting. Compliance with the checklists shall be monitored periodically to prevent non-adherence to checklists.
  • Training the staff: Ongoing periodical training focusing on patient safety and enhancing the culture of transparency is essential. Assuring the staff that their awareness is key to ensuring patient safety and that they play an important role in assuring quality delivery of care to patients is important.
  • Create a platform for reporting: Hospital leadership should create a platform to report the errors and make the system efficient to avoid future errors. Training and empowering the staff involved in the processes to identify the root causes and in eliminating them plays a huge role in a successful reporting system.
  • Root-cause analysis: Doing a root-cause analysis for all reported incidents helps in understanding the real cause, which most of the time may go beyond the human involved in the process. Identifying such causes through root-cause analysis shall help in the elimination of the correct contributing factor and also prevents the recurrence of errors.
  • Monitoring the processes: Monitoring and review of the safety processes continually ensures efficacy and helps in safer systems. The findings shall be used for further refinement of the processes and, if needed, update or modify to make the processes error-free.
  • Improve and continue: Periodical meetings to reinforce the organization's commitment to patient safety helps in continuous quality improvement. Regularly identifying and learning from defects helps in the prevention of error recurrences.
Figure 1: Surgical safety checklists. Checklist courtesy World Health Organization, Safe Surgery, Tool and Resources, accessed 3 May 2022, https://www.who.int/teams/integrated-health-services/patient-safety/research/safe-surgery/tool-and-resources

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Over the years, healthcare providers had viewed medical errors and adverse events as either an inevitable byproduct of complex care or the result of provider incompetence. In the process, the healthcare providers were often blamed for the error. Yet, most of the time, these situations occurred unintentionally. Humiliating or otherwise disciplining caregivers tend to perpetuate a culture of secrecy that impedes effective root-cause analysis and future improvement. No matter how well-intentioned, well-trained, and hard-working, healthcare providers are humans and can make mistakes. A more enlightened approach is entirely non-punitive and humans are protected from making mistakes by providing an enabling environment with safer systems, well-designed processes, and open and transparent reporting, where a safety culture prevails.[8]

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Global action on patient safety, Decision of Global patient Safety Action Plan 2021-30. 74th World Health Assembly, May2021. https://www.who.int/teams/integrated-health-services/patient-safety/policy/global-patient-safety-action-plan. [Last accessed on 2022 May 02].  Back to cited text no. 1
Global action on patient safety (resolution WHA72.26) https://apps.who.int/gb/ebwha/pdf_files/WHA72/A72_R6-en.pdf [Last accessed on 2022 May 02].  Back to cited text no. 2
AHRQ's Making Healthcare Safer Reports: Shaping Patient Safety Efforts in the 21st Century. Agency for Healthcare Research and Quality website. Available from: https://www.ahrq.gov/research/findings/making-healthcare-safer/index.html. [Last accessed on 2022 Jun 15].  Back to cited text no. 3
Neily J, Soncrant C, Mills PD, Paull DE, Mazzia L, Young-Xu Y, et al. Assessment of incorrect surgical procedures within and outside the Operating Room. A follow-up study from US Veterans Health Administration Medical Centers. JAMA Netw 2018;1:e185147.  Back to cited text no. 4
Simon JW, Ngo Y, Khan S, Strogatz D. Surgical confusions in ophthalmology. Arch Ophthalmol 2007;125:1515-22.  Back to cited text no. 5
Leape LL. Making Healthcare Safe. Available from: https://doi.org/10.1007/978-3-030-71123-8_2.  Back to cited text no. 6
Patient safety incident reporting and learning systems: Technical report and guidance. Geneva: World Health Organization; 2020. Available from: bit.ly/WHOsafe-report. [Last accessed on 2022 Jun 15].  Back to cited text no. 7
WHO guidelines for safe surgery 2009: Safe surgery saves lives. Geneva: World Health Organization; 2009. Available from: http://apps.who.int/iris/bitstream/handle/10665/44185/9789241598552_eng.pdf?sequence=1. [Last accessed on 2019 Jul 26].  Back to cited text no. 8


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