Strabismus Surgical Checklist Can Help Prevent Errors

One Third of Eye Surgeons Report Having Made Operating Room Errors

Ron Zimmerman

May 07, 2012

May 7, 2012 (San Antonio, Texas) — The Universal Protocol, designed to prevent wrong site, wrong procedure, and wrong patient surgical errors, can be insufficiently effective for strabismus surgery.

That's the conclusion of a study presented here at the American Association for Pediatric Ophthalmology and Strabismus 38th Annual Meeting. A checklist specifically tailored to strabismologists, which accounts for the specific errors made by eye surgeons, might improve surgical accuracy and prevent many common strabismus surgical errors.

Tina Rutar, MD, from the University of California at San Francisco, and colleagues surveyed 1103 surgeons and received responses from 517. One third of the respondents (173) reported making errors during surgery, a mean rate of 1 error per 2506 surgeries. Surgeons who performed fewer than the median of 1500 surgeries had an error rate 5.9 times higher than surgeons who performed more than the median (P = .001).

The types of errors included wrong procedure (35%), wrong muscle (22%), wrong eye (9%), and wrong patient (2%).

The most common source of error was confusion over esotropia/exotropia and/or recession/resection (20%).

The surgical load of the physicians was not a significant contributor to errors, but the number of surgical rooms used by the surgeon was (P =.13 and P = .02, respectively). A decreased likelihood of errors was associated with marking eye muscles prior to surgery (P = .03).

Dr. Rutar estimated that the Universal Protocol would have prevented only 16% of the errors in strabismus surgery.

Dr. Rutar told Medscape Medical News that she has a personal interest in this study; she wants to avoid ever making a surgical mistake herself. "I know it happens to the very best in our field [and] I've been very fearful that one day this will happen to me," Dr. Rutar explained. "I wanted to study this in a more systematic fashion to see if we can learn from the collective wisdom of our specialty."

She acknowledges the usual problems with a self-reported study, but believes there was no other way to gather the needed data. "Our survey was anonymous, precisely to get good reporting," she said. "We had a 47% response rate. That's a good survey rate for our busy surgeons, and 80% of them completed the survey in full, actually divulging the nitty-gritty details of their errors."

From the responses they received, Dr. Rutar's team concludes that a surgeon who has made a mistake sometime in their career is likely to be motivated to put preventive measures in place to prevent future errors. "Most surgeons had made only one mistake in their lifetime; fewer still had made a second mistake," she explained to Medscape Medical News. "If you have an error early in your career, it hits you hard. It changes the way you practice for the rest of your life."

If anything, Dr. Rutar hypothesized, the self-reported data may overreport surgical errors, because doctors who have made surgical errors might be overrepresented in the sample of doctors who responded to the survey. "Our reported error rate of 1 in 2500 is a very rough estimate, but it's the best we have because there are no other data out there."

Dr. Rutar described what she learned from the anecdotes reported by the survey respondents: "Especially in vertical muscle surgery, its really easy to get up/down muscle confusion. The situation where we're sitting at the patient's head and looking at the patient upside down, even though we've examined them right side up, only adds to that up/down, right/left confusion."

After presenting the survey results, Dr. Rutar concluded that a one-size-fits-all checklist might not be what the field needs. "I developed a checklist," she says, "but I'm hesitant to recommend it. When does a checklist become another bureaucratic detail and not make a difference in the end?"

She emphasized that the Universal Protocol is not a one-size-fits-all approach, but that each surgeon should have a specific checklist that makes sense for his or her own practice. She strongly recommends that doctors "tailor these error-prevention strategies to their own practices, because while their errors may not be career-ending, they can certainly be career-altering...and personally very devastating."

Based on the results of her survey, Dr. Rutar has 4 specific suggestions for checklists:

  • Empower other members of the surgical team to check that the surgical plan matches the patient's preoperative deviation

  • Mark the eye muscle and procedure, not just which eye itself

  • Use terminology that everyone in the operating room can understand, such as talking about "weakening" and "strengthening" muscles, not the more misunderstood technical "recess" and "resect" (specifically, do not write "rec" or "res," which can easily be mistranscribed and confused)

  • Consider making a dot at the limbus with a surgical marking pen before you begin manipulations, which can induce torsion, to help you stay oriented during surgery.

Devising a personal surgical checklist is exactly what long time surgeon James Mims III, MD, from San Antonio, Texas, has done. "I've bought multiple copies of [Atul] Gawande's The Checklist Manifesto and given them out to everyone on my staff," Dr. Mims said. "In the Air Force, I was impressed with the pilots who used long checklists, so I adopted checklists in my practice."

Dr. Mims said he uses a multistep process: marking up the patient, personally checking the patient's arm band twice, bringing the patient's chart into the operating room himself, and using the same scrub nurse for all his procedures.

Then during a "time out" before each surgery, he does one last check. "It's a click-your-heels, stand-at-attention kind of time out. We go through every step. At the end of the time out, we put a happy face sticker on the side we're going to operate on!"

Dr. Mims applauded the research. "It's a wonderful study. [Dr. Rutar's team has] probably saved some surgeon, and patient, a nightmare...with that survey."

Dr. Rutar has disclosed no relevant financial relationships.

American Association for Pediatric Ophthalmology and Strabismus (AAPOS) 38th Annual Meeting: Paper 2. Presented March 29, 2012