OPHTHALMOLOGY SAFETY CHECKLIST:

Donna U. Gramigna, RN, BSN, CPN(C)Hamza Khan, MD, MPH FRCSC FACSCourtney Addis, RN, BScN, MHSACarla Service, BScN, MPA, CHE

Improving Patient Safety- One Step at a Time

Financial Disclosures

• Donna Gramigna, RN, BSN, CPN(C): Has no financial interest.

• Hamza N Khan, MD, MPH FRCSC FACS: AlconAMOBausch and Lomb

• Courtney Addis, RN, BScN, MHSA: Has no financial interest.

• Carla Service, BScN, MPA, CHE: Has no financial interest.

Introduction

Surgical safety is a priority across health systems and for all providers. Utilizing a perioperative checklist may reduce the rate of certain ‘never events’1 such as wrong patient, wrong site, or wrong implant surgery. We found the development of a specific Ophthalmology checklist tool required an interdisciplinary approach.

Background • WHO sponsored Surgical Checklist study demonstrated a

50% reduction in perioperative morbidity in 8,000 cases across 7 countries in 3 continents.2 Related studies have shown the use of preoperative checklists reduced failures in communication by enhancing effective teamwork. 2, 3 A majority of errors in Cataract surgery may be prevented by the use of a pre-operative Time-Out.

• The original WHO Checklist does not capture common ophthalmology outcomes and includes several items not applicable.

• The use of surgical checklist is supported by Accreditation Canada.

• The WHO checklist was already being used in the organization’s main operating rooms.

Methods• Specific needs in Cataract surgery were identified by an

interdisciplinary working group (Surgeons, Nurses, QI Consultants, and OR Manager).

• An environmental scan was done of ophthalmology adaptations of the WHO checklist - including sites across Canada, United States, United Kingdom, and India.

• The new tool was developed around the existing Time-out function which was already in use. (See Fig. 1 for details.)

Methods (cont.)• Target: Primary goals: patient safety and good team

communicationSecondary goal: minimal impact on the high volume, rapid turnover setting of outpatient cataract surgery

• Review by surgical and nursing staff for further input prior to implementation.

• Data collection: Pre- and post-implementation reporting of significant incidents and “near misses”; opinion survey of team members on utility, impact on safety, team communications, and ease of use (Fig. 3).

Figure 1: Evolution of the Checklist

Ensuring patient safety is a fundamental element of high quality health care. To this end, VIHA is continually working to create a culture of safety within the organization. One way to do this is to improve the effectiveness and coordination of communication among health care providers and with care recipients.

VIHA has established a policy for all patients undergoing a surgical procedure. This purpose of this policy…11.3.10 Verification of Operative Procedure / Surgical Site…is to ensure that the indicated surgical procedure is performed on the correct patient and the correct side/ site prior to commencement of surgery, and it states that:

“Prior to the start of the procedure, the entire operating room team (surgeon, scrub/circulating nurse and anaesthesia) must take a “time out” to ensure that the correct patient is present and that everyone agrees on the procedure and body part involved.”

The following 5 checks should be made immediately prior to the start of a surgical procedure in Clinic 6:

Confirmation of the correct patient Correct side/site has been marked Agreement on the procedure to be performed (verified by signed consent) Availability of needed equipment/supplies/correct implant Allergies

The planned procedure is not started if a member of the team has concerns.

Points to Remember:

Performance of a time out should occur immediately prior to the procedure. Best practices suggest that the time out be led by the physician responsible for performing

the procedure with active involvement by all members of the team caring for the patient during the procedure.

Care must be taken to not make one member of the team feel responsible for the process when it clearly must be a joint endeavour.

The Time-Out Poster

The New Safety Checklist

The New Checklist

Results• Significant education was needed to implement the tool. One case of

wrong intraocular lens (IOL) was reported in both periods pre- and post-implementation. No statistical reduction in wrong IOL implants was seen. Staff reported better communication, including several near-misses, as indicated by 28% of the survey respondents (Fig. 3). Education and engagement of the entire surgical team resulted in better communication and workflow. Reports of near-miss incidents indicate that the tool is effective in reducing adverse events.

• Engagement of all front-line staff and scan of existing procedures allowed for a rapid and successful development of a specific checklist tool for cataract surgery.

Figure 3: Results of team survey questions. 

Strong

ly Disa

gree

Disagre

e

Neutra

l

Agree

Strong

ly Agre

e0%

10%20%30%40%50%60%

Checklist will Improve Team (Q7)

Pre-Implemen-tationPost-Implemen-tation

75%

8%17%

Thorough Timeout Performed (Q8)

75-100%50-75%25-50%25% or less

50%

21%

21%7%

Checklist Caught Near Miss (Q9)

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Conclusions• A low rate of ‘never events’ was reported

• Staff reports of ‘near-misses’ suggest the Checklist can improve patient safety

• The tool can improve team communication

• An Ophthalmology Checklist should be a standard of practice

References• Simon JW, Ngo Y, Khan S, Strogatz D. (2007) Surgical Confusions in

Ophthalmology. Archives of Ophthalmology, 125:1515-1522.  • Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AS, Dellinger EP,

Herbosa T, Joseph S, Kibatala PL, Lapitan MCM. Merry AF, Moorthy K, Reznick RK, Taylor B, & Gawande A. (2009). A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population. New England Journal of Medicine, 360(5):491-9.  

• Lingard L, Regehr G, Orser B, et al. (2008)  Evaluation of a Preoperative Checklist and Team Briefing Among Surgeons, Nurses, and Anesthesiologists to Reduce Failures in Communication. Archives of Surgery, 143: 12-8.

• Russo, C., Owens, P., Steiner, C. & Josephsen, J. (2007). Ambulatory Surgery in US Hospitals 2003. Agency for Healthcare Research and Quality.  

• Canadian Ophthalmological Society (2010). COS Statement on Value for Uninsured Services in Canada. Retrieved May 2010 from: www.eyesite.ca .