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Failure Modes and Effects Analysis of bilateral same-day cataract surgery.
Shorstein, Neal H; Lucido, Carol; Carolan, James; Liu, Liyan; Slean, Geraldine; Herrinton, Lisa J.
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  • Shorstein NH; From Kaiser Permanente (Shorstein, Lucido), Walnut Creek, Kaiser Permanente (Carolan), San Rafael, Division of Research (Liu, Herrinton), Kaiser Permanente, Oakland, and the California Pacific Medical Center (Slean), San Francisco, California, USA. Electronic address: nshorstein@eyeonsight.org.
  • Lucido C; From Kaiser Permanente (Shorstein, Lucido), Walnut Creek, Kaiser Permanente (Carolan), San Rafael, Division of Research (Liu, Herrinton), Kaiser Permanente, Oakland, and the California Pacific Medical Center (Slean), San Francisco, California, USA.
  • Carolan J; From Kaiser Permanente (Shorstein, Lucido), Walnut Creek, Kaiser Permanente (Carolan), San Rafael, Division of Research (Liu, Herrinton), Kaiser Permanente, Oakland, and the California Pacific Medical Center (Slean), San Francisco, California, USA.
  • Liu L; From Kaiser Permanente (Shorstein, Lucido), Walnut Creek, Kaiser Permanente (Carolan), San Rafael, Division of Research (Liu, Herrinton), Kaiser Permanente, Oakland, and the California Pacific Medical Center (Slean), San Francisco, California, USA.
  • Slean G; From Kaiser Permanente (Shorstein, Lucido), Walnut Creek, Kaiser Permanente (Carolan), San Rafael, Division of Research (Liu, Herrinton), Kaiser Permanente, Oakland, and the California Pacific Medical Center (Slean), San Francisco, California, USA.
  • Herrinton LJ; From Kaiser Permanente (Shorstein, Lucido), Walnut Creek, Kaiser Permanente (Carolan), San Rafael, Division of Research (Liu, Herrinton), Kaiser Permanente, Oakland, and the California Pacific Medical Center (Slean), San Francisco, California, USA.
J Cataract Refract Surg ; 43(3): 318-323, 2017 03.
Article en En | MEDLINE | ID: mdl-28410711
PURPOSE: To systematically analyze potential process failures related to bilateral same-day cataract surgery toward the goal of improving patient safety. SETTING: Twenty-one Kaiser Permanente surgery centers, Northern California, USA. DESIGN: Retrospective cohort study. METHODS: Quality experts performed a Failure Modes and Effects Analysis (FMEA) that included an evaluation of sterile processing, pharmaceuticals, perioperative clinic and surgical center visits, and biometry. Potential failures in human factors and communication (modes) were identified. Rates of endophthalmitis, toxic anterior segment syndrome (TASS), and unintended intraocular lens (IOL) implantation were assessed in eyes having bilateral same-day surgery from 2010 through 2014. RESULTS: The study comprised 4754 eyes. The analysis identified 15 significant potential failure modes. These included lapses in instrument processing and compounding errors of intracameral antibiotics that could lead to endophthalmitis or TASS, and ambiguous documentation of IOL selection by surgeons, which could lead to unintended IOL implantation. Of the study sample, 1 eye developed endophthalmitis, 1 eye had unintended IOL implantation (rates, 2 per 10 000; 95% confidence interval [CI], 0.1-12.0 per 10 000), and no eyes developed TASS (upper 95% CI, 8 per 10 000). Recommendations included improving oversight of cleaning and sterilization practices, separating lots of compounded drugs for each eye, and enhancing IOL verification procedures. CONCLUSIONS: Potential failure modes and recommended actions in bilateral same-day cataract surgery were determined using an FMEA. These findings might help improve the reliability and safety of bilateral same-day cataract surgery based on current evidence and standards.
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Texto completo: 1 Colección: 01-internacional Base de datos: MEDLINE Asunto principal: Extracción de Catarata / Endoftalmitis / Procedimientos Quirúrgicos Ambulatorios / Análisis de Modo y Efecto de Fallas en la Atención de la Salud Tipo de estudio: Etiology_studies / Guideline / Observational_studies / Prognostic_studies Límite: Humans Idioma: En Revista: J Cataract Refract Surg Asunto de la revista: OFTALMOLOGIA Año: 2017 Tipo del documento: Article Pais de publicación: Estados Unidos
Texto completo
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Texto completo: 1 Colección: 01-internacional Base de datos: MEDLINE Asunto principal: Extracción de Catarata / Endoftalmitis / Procedimientos Quirúrgicos Ambulatorios / Análisis de Modo y Efecto de Fallas en la Atención de la Salud Tipo de estudio: Etiology_studies / Guideline / Observational_studies / Prognostic_studies Límite: Humans Idioma: En Revista: J Cataract Refract Surg Asunto de la revista: OFTALMOLOGIA Año: 2017 Tipo del documento: Article Pais de publicación: Estados Unidos