Enhancing safety in ophthalmic surgery: Database analysis of intraocular lens implantations in Japan for classification of human errors
Objectives: Intraocular lens (IOL) implantation is a common and frequently performed surgical procedure. While errors are rare, they continue to occur, which indicates the current countermeasures are insufficient. Our aim was to analyze IOL implantation errors in Japan, classify the errors into diff...
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| Main Authors: | , |
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| Format: | Article |
| Language: | English |
| Published: |
Elsevier
2025-06-01
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| Series: | Human Factors in Healthcare |
| Subjects: | |
| Online Access: | http://www.sciencedirect.com/science/article/pii/S2772501425000144 |
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| Summary: | Objectives: Intraocular lens (IOL) implantation is a common and frequently performed surgical procedure. While errors are rare, they continue to occur, which indicates the current countermeasures are insufficient. Our aim was to analyze IOL implantation errors in Japan, classify the errors into different types, and propose countermeasures specific to each error type to prevent them from occurring. Methods: Incident reports of incorrect IOL implantations from the Japan Council for Quality Health Care database (2010–2020) were reviewed. Two researchers analyzed each incident report to identify the critical error, which was classified as a slip (i.e., performance error), lapse (i.e., memory error), mistake (i.e., rule- or knowledge-based error), or violation (i.e., deviation from normal operating procedure). Results: Out of 57 incidents, three were excluded due to insufficient information. Among the 54 remaining incidents, the most common critical error was a slip (n = 31, 57.4 %) followed by mistakes (n = 16, 29.6 %), violations (n = 4, 7.4 %), and lapses (n = 3, 5.6 %). Critical errors occurred during the IOL selection (n = 16, 29.6 %), preparation (n = 21, 38.9 %), and implantation (n = 17, 31.5 %) stages. Slips tended to occur in earlier stages while mistakes were more frequent in later stages. Conclusions: The predominant errors in incorrect IOL implantations were slips and mistakes. Developing preventive measures specific to each error types is crucial. Slips can be mitigated by implementing safety procedures such as checklists and standardized protocols. Mistakes often occur in nonstandard situations, so prioritizing effective communication and nontechnical skills among team members will help ensure their psychological safety and improve their overall performance in clinical settings. |
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| ISSN: | 2772-5014 |