Risk Management

Preop Planning Can Prevent Mix-Ups in the OR

By Oksana Mensheha, MD

Argus, March, 1993

Among a small group of ophthalmologists I talked with, more than half acknowledged that they had either personally operated on the wrong eye or knew someone who had. Their experiences ranged from performing a cataract extraction on the wrong eye and doing an esotropic procedure on an exotropic child to removing the wrong eye for a malignant melanoma. Surgeons who have not actually operated on the wrong eye admit they have come close.

What can we do to prevent such mix-ups from occurring?

When doing cataract surgery, I find it helpful to record the A-scan by itself for the eye to be operated on and to post this on the wall of the OR. I record the results for the right eye on the top half of a sheet of paper:

Kod=

ALod=

Order Lens Power od=

I record the results for the left eye on the bottom half of another sheet of paper. I try to avoid recording both A-scans in the same place because it can be confusing. Of course, both eyes can be scanned at the same time, but it takes little effort to record the results separately.

I also find it helpful to bring my office chart into the OR. My office chart documents the scheduling of the surgery and has multiple indications of which eye is to be operated on. If I have a chance to see the patient preoperatively, I try to make certain the dilated eye is the preop eye noted in my office record. I also try to verbally confirm this with the patient. Another safeguard some surgeons use is to preoperatively mark the eye to be operated on with a marking pen.

Performing the wrong procedure on a strabismic child can also prevent significant problems. Some children’s eyes can appear to be straight under general anesthesia, adding to the confusion. If possible, try to examine the child before the anesthesia. In the case in which the ophthalmologist performed surgery for an esotropia instead of an exotropia, the child was wearing the wrong name tag, and the operating rooms had been switched.

Such a mix-up might be avoided if the parents identify the child prior to surgery, or if preop photographs are available for each child scheduled for surgery that day. Once in the OR, a quick check of the photos together with the office record will confirm that the correct child is in the OR, receiving the proper surgery.

The most serious event I heard about was the removal of a healthy eye instead of an eye with melanoma. The diseased eye subsequently was removed. Again, bringing well-documented office records into the OR might have prevented this occurrence. Dilating the proper eye as well as marking an “X” above the eye preoperatively also might have helped. Finally, with irreversible procedures such as enucleation, consider examining the eye with indirect ophthalmoscopy before proceeding.

No system is foolproof. However, referring to your office record when you are in the OR, after ensuring that the record matches the patient to be operated on, can be a tremendous help in avoiding surgery on the wrong eye.