Risk Management

Preventing Wrong Events

July 10, 2023

Dear OMIC Insureds:

Whether you call them wrong events or never events, one thing is universal: you never want them to happen to you. In ophthalmology, WSPEs (wrong-site, wrong-procedure, wrong-patient errors) can lead to severe reactions to medications, additional surgery, decreased vision, and even blindness. Furthermore, WSPEs almost always lead to claims and require settlements to resolve.

We often read that wrong events are avoidable. If that’s true, why are they still happening? How do we get closer to achieving a zero-error environment?

Analysis of errors and near misses reveal how systems and protocols failed and allowed the event to happen; it also reveals how organizational culture may have contributed. Use the findings of such analyses to improve safety protocols. For example, implantation of the wrong lens occurs more frequently than it should, and is often the result of a last-minute change to the OR schedule. In the office, we continue to see errors with patient identification, leading to wrong-patient, wrong-procedure errors.

Assess whether the values and behaviors of the current culture comport with your desired goals and standards. A culture that values continuous learning and improvement, and honest communication, is more likely to result in staff who feel empowered to report an error, a near miss, or a potential weakness in the system.

As Reason’s Swiss cheese model[1] explains, no one safety protocol will prevent an error. Therefore, periodically reviewing and improving your patient safety protocols will help decrease the likelihood of error.

OMIC has resources on preventing WSPEs on our website:

https://www.omic.com/wp-content/uploads/2016/02/Ophthalmic-Surgery-Checklist.pdf
https://www.omic.com/wrong-sitewrong-iol-aao/
https://www.omic.com/time-out-before-intravitreal-injections-2/
https://www.omic.com/wp-content/uploads/2021/09/Digest-Vol-31-No-1-2021-.pdf

If you have questions about this topic, contact our Risk Management Hotline for confidential consultation: riskmanagement@omic.com or 800-562-6642 and enter 4.

Sincerely,

Linda D. Harrison, PhD
Vice President, Risk Management

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[1] Reason J. Human error. New York: Cambridge University Press; 1990.

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