Anything wrong with this attitude?

[Euripides]

I’m an anesthesiologist needing insight. I work in a few surgery centers that do ophthalmology cases. In the last few months I’ve seen a couple of cases where the paperwork from the ophthalmologist’s office has had erroneous lens information but this is only discovered after the fact. This results in the patient receiving the wrong lens which isn’t discovered by the surgeon until a post-op visit. The ASC staff did everything correctly because they provided the lens that was requested by the surgeon, did all the appropriate checks (time-outs, etc.) but the fact is that the information they were working from was incorrect and they had no way to know otherwise. To my surprise the surgeons seem unfazed by this and just reschedule the patient for a subsequent lens exchange to put the correct one in place. They admit that there was an error in their office but seem nonplussed that the patient has to face another procedure. For what its worth the ASC comps the fees for both the original and subsequent procedures and all that but it doesn’t feel right to me that this is seen as acceptable. These are different ophthalmologists in unrelated practices in different ASCs so I’m not speaking about one outlying physician.

My question for you is this common elsewhere and are my feelings that we are shortchanging patients unfounded? We do lots of these cases so the incidence of this is low but I’m curious as to whether this is seen as a normal course of practice that sometimes bad things happen.

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[LightBox]

Amazingly, ophthalmologists are human too and if each of them is doing 1000 to 2000 cases a year, a wrong IOL is bound to be put in on occasion. I've personally put in two "incorrect" IOLs during my career, but due to the fact the patients wanted monovision and somehow that wasnt documented in the chart. In the grand scope of things, IOL exchanges are not a big deal. But definitely annoying and inconvenient for both the patient and surgeon. Trust me, one's reputation does not improve if you are doing IOL exchanges all of the time!
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[Euripides]

Amazingly, ophthalmologists are human too and if each of them is doing 1000 to 2000 cases a year, a wrong IOL is bound to be put in on occasion. I've personally put in two "incorrect" IOLs during my career, but due to the fact the patients wanted monovision and somehow that wasnt documented in the chart. In the grand scope of things, IOL exchanges are not a big deal. But definitely annoying and inconvenient for both the patient and surgeon. Trust me, one's reputation does not improve if you are doing IOL exchanges all of the time!
.

I appreciate your feedback. I got drawn into this topic mostly because one of the ASCs had a wrong site surgery as well in another patient and the staff (medical and nursing) debated whether there was a difference philosophically between a wrong arthroscopy and a wrong lens implant.

 

[DoctwoB]

Disagree with above. This is and should be a “never event” like a wrong sided surgery. Of course in practice a never event is a misnomer. Anytime you are doing thousands of cases with dozens of potential implants a mistake will happen. But from a malpractice standpoint it is indefensible. And from a systems standpoint you need to understand that human error and miscommunication will happen, so things like implants need to be confirmed in clinic, in preop, and Intraop. Putting in the wrong lens is much more recoverable event then taking out the wrong kidney, but that doesn’t make it any more acceptable.

 

[dantt]

I’m an anesthesiologist needing insight. I work in a few surgery centers that do ophthalmology cases. In the last few months I’ve seen a couple of cases where the paperwork from the ophthalmologist’s office has had erroneous lens information but this is only discovered after the fact. This results in the patient receiving the wrong lens which isn’t discovered by the surgeon until a post-op visit. The ASC staff did everything correctly because they provided the lens that was requested by the surgeon, did all the appropriate checks (time-outs, etc.) but the fact is that the information they were working from was incorrect and they had no way to know otherwise. To my surprise the surgeons seem unfazed by this and just reschedule the patient for a subsequent lens exchange to put the correct one in place. They admit that there was an error in their office but seem nonplussed that the patient has to face another procedure. For what its worth the ASC comps the fees for both the original and subsequent procedures and all that but it doesn’t feel right to me that this is seen as acceptable. These are different ophthalmologists in unrelated practices in different ASCs so I’m not speaking about one outlying physician.

My question for you is this common elsewhere and are my feelings that we are shortchanging patients unfounded? We do lots of these cases so the incidence of this is low but I’m curious as to whether this is seen as a normal course of practice that sometimes bad things happen.

It is unclear what exactly happened in this situation. Was there a transcription error from measurement to lens calculations? Was the wrong patient information used? Did the surgeon erroneously choose the wrong lens type when they meant to choose another? Did the patient simply have a refractive surprise? Hard to comment unless we understand the specifics.

 

[Euripides]

In each of the cases the errors occurred in the office and were seemingly unpreventable by the ASC staff. One was a transcription error In the office (incorrect information copied onto paperwork whereby OS info recorded erroneously for OD and vice versa). In this case the patient narrowly averted having two incorrect lenses implanted and was actually in the ASC for the second eye procedure but was complaining of poor vision leading the ASC staff to ask the surgeon if there could be a problem. Another instance was office paperwork reflected calculations from an earlier refraction visit and office staff didn’t send over most recent lens calculation. Third case was similar to second but in this instance the office somehow detected the error and called the ASC while the patient was still in the building so the lens swap took place with a second surgery the same day. All three situations were out of the control of the ASC staff.

 

[xlr8]

From a systems standpoint you can suggest that the actual IOL calculation sheet be used in the OR/time-out instead of a transcription. A refraction visit and repeat lens calculation would likely not significantly change the lens power--the values are pretty static over time.

 

[hurdlepup]

Disagree with above. This is and should be a “never event” like a wrong sided surgery. Of course in practice a never event is a misnomer. Anytime you are doing thousands of cases with dozens of potential implants a mistake will happen. But from a malpractice standpoint it is indefensible. And from a systems standpoint you need to understand that human error and miscommunication will happen, so things like implants need to be confirmed in clinic, in preop, and Intraop. Putting in the wrong lens is much more recoverable event then taking out the wrong kidney, but that doesn’t make it any more acceptable.

I would say you have no experience with this then. I did this personally one time in residency because the computer somehow placed the lens calculations from one patient into another patient’s chart. In residency, I stopped an attending who is very good from putting in the wrong lens one time. It just happens. Because you have done the pre op measurements ahead of time, you can double and triple check them all you want on the day of surgery but if there is an error in the actual calculations themselves then having those checks will not matter. Not saying you shouldn’t also confirm with an additional time out at the time of lens placement as well but these things will happen from time to time. They should be rare and it’s not a fun conversation to have with the patient.


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[MstaKing10]

I appreciate your feedback. I got drawn into this topic mostly because one of the ASCs had a wrong site surgery as well in another patient and the staff (medical and nursing) debated whether there was a difference philosophically between a wrong arthroscopy and a wrong lens implant.

There really is not if it is identified that a systems error in the ASC caused the error. For example the correct lens was asked for by the surgeon but wrong lens given by circulator, or innapropriate time out procedures or the like. There are some very good guidelines on this from the AAO, OMIC and others. This might be a good opportunity to re evaluate the ASC procedure for IOL surgery.

Were these cases by one surgeon? Or clustered around the same time? These events are rare, but if you are in a high volume ASC with multiple surgeons over the course of years having a few of these cases is probably not out of line (for the ASC). Now if it’s one doc, then there is a major problem.

As to your original post, is there an attitude problem, I guess it depends. This is a huge issue and surgeons never like having to go back to operate especially for a preventable error. The amount of chair time spent with the patient and angst for the surgeon is huge. That said, they are unlikely to show up to the ASC for a reop and make a huge deal about it there, by that point all these issues have been sorted out in the office. Not sure what reaction you expect to see day of surgery. Again, if this is same surgeon then there’s an issue.

 

[airplanes]

Exactly the above. What did you expect, a distraught surgeon on the day of surgery? Would that have been helpful for anyone? How do you know steps have not been taken in their office to minimize any similar mistakes? In the ASC/OR setting, you would really not be privy to any office changes or safeguards since the ASC/OR procedural steps would not have prevented the incident.

Regarding the philosophical "debate." A wrong IOL is not the same as wrong site where a procedure was performed on incorrect tissues and anatomy. It would be more similar to an incorrectly sized knee replacement device. Thankfully, in the case of a wrong IOL, the procedure to "fix" the incorrect implant is safe, effective and you would expect the patient to really do just as well after appropriate recovery. Could you say the same about going in to healing knee twice?

 

[hello lady!]

I agree that wrong IOL isn't necessary equal to a wrong-site surgery, but it should trigger some sort of root cause analysis. Even though it's relatively safe to do a lens exchange, the risk is not zero so it is an error that raises the patient's risk.

The older generation of docs are going to be the ones who want to bury it under the rug. It's the new generation that is more likely to look into it as a systems issue.

 

[Dusn]

How many cases a day were those ophthalmologists who put in the incorrect IOL or performed a wrong-site surgery doing?