Ophthalmology moves toward a culture of safety

April 15, 2017

In 1999, an Institute of Medicine report estimated that as many as 100,000 deaths potentially occurred each year in hospitals because of medical errors. In a 2001 JAMA article, Rodney A. Hayward, M.D., and Timothy P. Hofer, M.D., M.S., found that up to 23 percent of patient deaths were preventable with optimal care.

Today, "patient safety focused on a reduction in both procedural and diagnostic errors is the No. 1 concern of the U.S. health care system," says George B. Bartley, M.D., an ophthalmologist at Mayo Clinic's campus in Rochester, Minnesota. "In ophthalmology, a culture of safety aims to minimize medical errors and harm to patients while providing care of the highest quality — as well as working to ensure the safety of the eye care team."

Dr. Bartley and a team of peers presented their 2016 study, Building a Culture of Safety in Ophthalmology, at the American Board of Ophthalmology 100th Anniversary Symposium. The study also was published in a special supplemental issue of Ophthalmology.

"In the past decade, there has been a tremendous focus on patient safety and building health care delivery systems that make errors less likely to occur," says Dr. Bartley. "There has been a paradigm shift in health care: from personal responsibility to teamwork and shared responsibility, from individual care preferences to standardized systematic care processes, from culpability and punitive responses to open reporting and a just culture, and from the idea that people fail to the approach that systems fail and that those systems can be re-engineered successfully. The synergy between patient safety and occupational safety in hospitals, in particular, has been noteworthy."

Patient safety issues

Dr. Bartley notes: "Diagnostic error may be both the most important and most challenging safety issue in medicine today. Wrong diagnosis, delayed diagnosis and failure to communicate diagnostic results lead to patient harm and are the most frequent cause and greatest cost of malpractice claims.

"Wrong surgery, and in particular wrong intraocular lens insertion, is arguably the most visible patient safety issue in ophthalmology. These mishaps are preventable and their persistence has gained the attention of state and federal entities. Wrong surgery is not isolated to cataract extraction, however. Nearly 34 percent of pediatric ophthalmologists report being involved in a wrong patient, wrong eye or wrong procedure incident during their careers.

"Patients can be exposed to other injuries, too, such as toxic anterior segment syndrome, endophthalmitis resulting from contaminated compounded drugs, or thermal injury. Communication errors are a frequent cause of patient safety mishaps, and outpatient prescription mistakes are not uncommon. Undetected drug side effects are a serious safety issue, as is incorrect preoperative management of anticoagulants."

Culture of workplace safety

A culture of safety in medicine has defined elements that decrease the rates of error and patient harm within work teams, including:

  • Acknowledgment of the high-risk nature of the team's activities and a commitment to consistently safe operations
  • An environment that is blame-free, in which team members are encouraged to report errors or near misses without fear of punishment
  • Support of collaboration across ranks and disciplines to seek solutions to patient safety issues
  • Commitment of resources to address safety concerns

A culture of safety includes protecting the ophthalmic team from physical injury. "Sharps injuries often go unreported and the nature of ophthalmic practice, such as frequent use of operating microscopes, puts ophthalmologists at particular risk of neck and back injuries," says Dr. Bartley.

A culture of safety also requires respectful behaviors among and between the members of the team. Dr. Bartley notes: "Lack of respect may underlie other conditions detrimental to patient care, such as staff burnout. Without a culture of respect, it may be impossible to create and sustain a culture of safety."

A work in progress

The establishment and sustenance of a safety culture within an organization are associated with significant institutional performance improvement, not only in reductions in sentinel adverse events and near misses, but also in enhanced financial results, operational efficiency and patient outcomes.

"Encouraging progress has been made," says Dr. Bartley. "The Agency for Healthcare Research and Quality's 2015 report 'Saving Lives and Saving Money' documented a 17 percent decline between 2010 and 2014 in a broad range of hospital-acquired conditions. Patients experienced approximately 2.1 million fewer hospital-acquired conditions during this interval, resulting in approximately 87,000 fewer deaths and almost $20 billion in health care savings."

For more information

Kohn LT, et al., eds. To Err Is Human: Building a Safer Health System. Washington, D.C.: National Academy Press; 2000.

Hayward RA, et al. Estimating hospital deaths due to medical errors: Preventability is in the eye of the reviewer. JAMA. 2001;286:415.

Custer PL, et al. Building a culture of safety in ophthalmology. Ophthalmology. 2016;123(9 suppl):S40.

Saving lives and saving money: Hospital-acquired conditions update. Rockville, Md.: Agency for Healthcare Research and Quality.