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John W. Simon, MD; Yen Ngo, MD; Samira Khan, MD; David Strogatz, PhD

Arch Ophthalmol. 2007;125(11):1515-1522.

Objective  To investigate the hypothesis that surgical confusions rarely occur but are unacceptable to the public; occur in predictable circumstances; involve a wrong lens implant more often than a wrong eye, procedure, or patient; and can be prevented using the Universal Protocol.

Methods  A retrospective series of 106 cases, including 42 from the Ophthalmic Mutual Insurance Company and 64 from the New York State Health Department. We investigated how the error occurred; when and by whom it was recognized; who was responsible; whether the patient was informed; what treatment was given; what the outcome and liability was; what policy changes or sanctions resulted; and whether the error was preventable using the Universal Protocol.

Results  The most common confusion was wrong lens implants, accounting for 67 cases (63%). Wrong-eye operations occurred in 15 cases, wrong-eye block in 14, wrong patient or procedure in 8, and wrong corneal transplant in 2. Use of the Universal Protocol would have prevented the confusion in 90 cases (85%).

Conclusions  Surgical confusions occur infrequently. Although they usually cause little or no permanent injury, consequences for the patient, the physician, and the profession may be serious. Measures to prevent such confusions deserve the acceptance, support, and active participation of ophthalmologists.

Author Affiliations: Department of Ophthalmology, Lions Eye Institute, Albany Medical College, Albany, New York (Drs Simon, Ngo, and Khan); and Department of Epidemiology and Biostatistics, State University of New York, Albany (Dr Strogatz).

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