Risk Management

The Irreducible Minimum: When Is Enough, Enough?

By Michael R. Redmond, MD

Argus, January, 1993

No matter what type of medical and/or surgical intervention is recommended, accepted and undertaken, there is always the risk of a maloccurrence and possibly a secondary complication resulting in permanent damage.

One area of potential risk often overlooked in discussions with patients concerns the technical portion of surgery. Mechanical or electrical equipment failures, or the breaking off and loss of needle portions for example, are rare but potentially serious occurrences. Others, such as perforation of the globe during strabismus surgery, happen more frequently (perforation of the globe has been reported to occur in 20-30% of strabismus surgeries), but rarely lead to complications.

What should we tell our patients? How far down the statistical risk table should we go? There is no absolute answer. The ophthalmologist must in each individual case, provide the patient or the family with enough information to make an informed decision. To simply tell the patient that he or she could lose an eye from the surgery or die from the anesthetic is not enough. An uncomfortable unsightly eye may be more unacceptable to the patient than total loss of vision and surgical removal of the globe. The threat of a vegetative state from anesthesia might be feared more than death itself.

As always, preoperative discussion with an appropriate warning of potential risks that a reasonable, informed patient would care about is most important. Even with the incident of strabismus surgery perforation, the ophthalmologist can explain that this rarely causes a problem, in spite of its relatively frequent occurrence. Also, the physician can discuss the thickness (or thinness) of the sclera, the special-shaped needle used, and so on in order to show the consideration and care given to the issue.

If any complication or maloccurrence happens that might jeopardize the patient, the ophthalmologist should immediately disclose the appropriate information to the patient and note this in the chart. Disclosure should not be delayed in order to see what happens over time.

We all know there is an irreducible minimum for maloccurrence and complications. Only by making and keeping the patient a true “partner” in the choice of his or her care and throughout the continuum of that care can we as ophthalmologists bring our risk down to the irreducible minimum.