Risk Management

Miscommunication During PRK Leads to Surgical Mix-up

By Randy Morris, JD
OMIC Claims Associate

Digest, Winter 2001

ALLEGATION  Improper performance of PRK procedure.

DISPOSTION  Case settled on behalf of codefendant ophthalmologist and insured laser center.

Case Summary

A 33-year-old male patient was scheduled to undergo a bilateral PRK procedure at an OMIC-insured laser center. Based upon the surgeon’s preference card maintained at the laser center, the technician added a laser epithelial removal treatment folder to the treatment cards for both eyes before the start of surgery. Upon arriving at the laser center, the surgeon indicated that she intended to perform an alcohol scrape of the epithelium instead of a laser epithelial removal. The technician removed the laser epithelial removal folder for the left eye only. Once the patient was positioned in the laser chair, another technician took over and assisted the surgeon with the PRK on the left eye.

After the left eye had been treated, yet another technician took over for the procedure on the right eye. Both the surgeon and the newest technician looked at the computer monitor to confirm the treatment plan; both failed to realize that a laser epithelial removal folder was still programmed for the right eye. As a result, a laser scrape was performed on the right eye even though an alcohol assisted epithelial scrape already had been performed. Both the surgeon and the technician were mistakenly under the impression that PRK was being performed when in reality a laser epithelial removal of 40 microns was occurring. When the laser stopped after the epithelial removal, the screen showed the pre-programmed PRK treatment. At this point, they both realized the mistake and terminated the procedure without performing the PRK on the right eye. Ultimately, the patient underwent LASIK with an enhancement by a different surgeon. The patient eventually achieved 20/20 vision in the right eye, although he continued to complain of blurry vision. Corneal topography confirmed a central island defect.

Analysis

The codefendant surgeon was relatively inexperienced in the use of the laser and did not recognize the difference in appearance of the epithelial removal screen and the PRK screen. Nor did she distinguish the difference in sound between the full 6.5-mm beam ablating the cornea in the laser epithelial removal mode and the softer sound of the initially small beam ablating the cornea in the PRK mode.

According to the laser’s operating manual, the surgeon is responsible for the treatment plan. Experts for both sides agreed there was liability on the part of the surgeon, but were less certain about the exposure of the laser center. A jury might have found the laser center liable for allowing the technicians to switch in the middle of the two procedures. Additionally, the surgeon was quick to blame the technicians, who were employees of the laser center, for the mix-up. Since the defense did not have any expert support on the standard of care issue, liability would have to be conceded and the case tried solely on the issue of damages. In view of this, the codefendant surgeon and insured laser center agreed to settle rather than go to trial.

Risk Management Principles
This case illustrates the need for all surgical personnel to communicate clearly regarding treatment plans before beginning treatment. While this may be stating the obvious, it is surprising how many times a simple communication breakdown is at the heart of a malpractice suit. A system of checks and double-checks will go a long way toward preventing this type of situation. Additionally, the seemingly random “tag teaming” of technicians that occurred in this case should be avoided by requiring that the same surgical personnel be present for the entire procedure.