Building Safer Eye Surgery Systems

Surgeons are acutely aware of the privilege and responsibility of restoring sight. When preventable adverse events such as the implantation of the wrong lens, a missed emergency, or toxic anterior segment syndrome (TASS) occur, the consequences can be devastating for patients and staff alike. We believe that the most powerful response is to turn each incident into an opportunity to strengthen systems. As we teach in the Seva Foundation’s Quality Network and at Zamindar Microsurgical Eye Centre, the path to safer surgical care lies in building a culture that empowers all staff to report, analyze, and act upon risks in a transparent, blame-free manner.

This article shares practical insights drawn from the Corrective and Preventive Action Guide for Common Adverse Events in Eye Hospitals (visit bit.ly/sevaguide), a resource developed by Seva Foundation in collaboration with partners across Nepal, India, and Cambodia.

FOUNDATIONS OF A REPORTING CULTURE

Patient safety begins with the staff’s psychological safety. In too many institutions, staff hesitate to report errors or near misses out of fear of punishment. We instead embrace the systems approach to medical errors advocated by Lucian Leape, MD, a professor at the Harvard School of Public Health, that focuses on identifying systemic factors that contributed to a mistake rather than blaming individuals. The approach, in other words, recognizes that most people try to do a good job but make simple mistakes and it is the processes that set them up to make these mistakes.

At Zamindar Microsurgical Eye Centre, and across Seva partner hospitals, we explicitly reinforce that incident reporting is encouraged and no one will be punished for doing so. A simple incident report form captures both adverse events and near misses because learning from events that almost happened is equally valuable.

Training emphasizes that even expected complications merit reporting if they reveal opportunities for systemic improvement. Examples include corneal edema after TASS, a fall after pupillary dilation due to missed escort instructions, or a delay in cardiopulmonary resuscitation revealing unclear team roles.

PRIORITIZING EMERGENCIES IN THE OUTPATIENT DEPARTMENT

One area of vulnerability is the outpatient triage process. We analyzed multiple potential events where serious eye or medical emergencies—such as acute angle closure or myocardial infarction—were not prioritized in time.

Using fishbone analysis and the 5 whys method (see the sidebar for details on these methodologies), teams identified the following contributing factors:

• An insufficient number of staff members trained to recognize emergencies;
• The lack of a standard operating procedure (SOP) for triage;
• Inadequate communication between front desk and clinical staff; and
• No dedicated emergency response room.
• The following preventive actions were subsequently taken:
• Developed a clear triage policy and training module;
• Introduced color-coded emergency patient cards;
• Assigned floor facilitators to monitor for patients at risk; and
• Implemented audits of emergency response timelines.

These changes were low in cost and rapidly scalable, and they could make a tangible difference in patient outcomes across our network.

LESSONS FROM IOL ERRORS

Perhaps no error is more painful than the implantation of the wrong IOL. It is a profound violation of patient trust—and one that must be guarded against.

One hypothetical event analysis found that the absence of a formal surgical time-out, combined with the following factors, could result in an incorrect IOL’s being placed:

• Illegible handwriting;
• Mismatched biometry printouts;
• Poor team communication; and
• Variable adherence to SOPs.

In response, we encouraged a strict “sign-in, time-out, sign-out” process, improved the clarity and traceability of biometry records, limited biometry to trained staff only, and established a high-alert protocol for patients with similar names. We advocate for surgical time-out to be as sacred as hand hygiene. Both are nonnegotiable, every case, every time.

ENVIRONMENTAL VIGILANCE

The guidebook we created also highlights lessons from potential TASS outbreaks. Potential causes identified included lapses in equipment cleaning; the malfunction of heating, ventilation, and air conditioning systems; and supplier changes without adequate validation.

Key preventive actions included the following:

• Monthly monitoring of water and air quality;
• Strict flushing of hollow instruments;
• Ethylene oxide residual testing;
• Formal validation of new consumables; and
• Strengthened OR environmental cleaning protocols.

The lesson we learned is as follows: TASS prevention demands a systems approach that goes far beyond surgical technique.

MEDICATION SAFETY

From inadvertent pupillary dilation in patients with angle closure to unrecorded drug allergies, medication-related events are a safety issue worldwide.

Our partners recommended the following practical steps:

• Electronic health record allergy alerts;
• Staff credentialing for the instillation of mydriatics;
• Improved drug labeling and storage audits; and
• SOPs for history taking and medication administration.

The simple act of documenting a patient’s known allergy—and ensuring the information is reliably visible across every point of care—has prevented repeat reactions in many situations.

BUILDING A LEARNING SYSTEM

Ultimately, checklists and SOPs are not enough. We strive to cultivate an environment where every staff member is a sensor for risk, every incident is an opportunity for team learning, and leadership visibly champions patient safety as a core value.

The culture of an organization is deeply influenced by its long-serving support staff, whose habits and practices often become embedded over time. When these age-old habits no longer align with today’s safety standards, however, they must be transformed. Achieving this behavioral change requires a sustained effort that includes regular training, consistent encouragement, and ongoing monitoring to support and reinforce regular incident reviews and cross-institutional learning—as we do through Seva’s quality network.

CONCLUSION

Our experience has shown that structured corrective and preventive action processes can transform how eye hospitals manage risk. All adverse events should be reported and analyzed, and continuous monitoring of adverse events is an important part of continuous quality improvement in patient safety goals. Root cause analysis is the planning needed to put your preventive action in place. By sharing what we have learned, we hope to inspire fellow cataract and refractive surgeons to foster an environment in which reporting incidents is safe, root cause analysis is routine, preventive actions are championed; and patients receive the safest, most compassionate care possible.

We welcome collaboration with all colleagues on this journey. An adverse event at a hospital is not a failure but an opportunity to make the system safer for the next patient.

Editor’s note: The authors would like to thank Lisa Brothers Arbisser, MD, for shining a light on this work.