Risk Management

Presurgical Checklists Promote Good Documentation Practices

By Dean C. Brick, MD

[Digest, Fall, 1991]

A presurgical checklist helps ensure that all aspects of surgery, including informed consent, patient compliance and postoperative complications, are discussed with the patient. This cataract surgery checklist was developed by Byron H. Demorest, MD, and Richard A. Deutsche, MD, of the OMIC Risk Management Committee.

Prior to scheduling surgery

Alternative therapies have been explained.

No surgery

Surgery

Procedure electives have been discussed.

Spectacles

Contact lenses

IOL

Postoperative complications have been discussed with patient and, if appropriate, with patient’s family.

Patient has been told that results are not guaranteed and surgery could result in:

No improvement in vision

Worse vision (even total blindness)

Improvement in vision

Patient has been told that the implant might have to be removed, replaced, or become dislocated and have to be repositioned.

Patient has been told about other possible complications of surgery including:

Astigmatism

Image size difference

Need for prolonged medication

Infection

Retinal detachment

Corneal damage

Double vision

Hemorrhage

Lid droop

Pupil distortion

Pain

Glaucoma

Uveitis

Capsule clouding requiring laser treatment

Anesthesia options have been reviewed (general or local) and patient has been told about possible complications of anesthesia including:

Drug reactions

Brain damage

Death

At appointment preceding surgery

Informed consent form has been reviewed and signed.*

Medical evaluation has been performed.

Preoperative eye exam has been performed.

Visual acuity

Description of cataract

IOP

Macular function

Appearance of the optic nerve

Lab tests have been performed, if indicated, and reviewed.

CBC

Urinalysis

Chempanel

EKG

Chest x-ray

Patient’s medication and medical history have been reviewed.

Is patient currently taking any medications?

Is patient allergic to any medications?

IOL calculations reviewed.

Determine proper IOL power

IOL has been ordered.

Posterior chamber lens

Anterior chamber lens

No implant

Patient has been instructed on preoperative facial care.

Facial cleansing prior to surgery

No cosmetics on day of surgery

Patient has been instructed on any preoperative drops.

Patient has been instructed on diet on day of surgery.

Patient has been told what time to arrive for surgery and what time to expect to be able to go home.

Patient has arranged an escorted ride to and from surgery.

Postoperative follow-up appointment has been scheduled.

Eye has been examined for infection of globe and lids.

On the day of surgery

Confirm patient’s name.

Confirm which eye for surgery.

Prior to mydriatic drop, look for signs of discharge or infection of globe or lids.

Confirm that you have the correct IOL for that patient when you are in the operating room.

* Note in patient record that alternative therapies, risks and complications have been reviewed and signed by the patient and witness.