Sources of medical error in refractive surgery

摘要

PURPOSE: To evaluate the causes of laser programming errors in refractive surgery and outcomes in these cases. METHODS: In this multicenter, retrospective chart review, 22 eyes of 18 patients who had incorrect data entered into the refractive laser computer system at the time of treatment were evaluated. Cases were analyzed to uncover the etiology of these errors, patient follow-up treatments, and fi nal outcomes. The results were used to identify potential methods to avoid similar errors in the future. RESULTS: Every patient experienced compromised uncorrected visual acuity requiring additional intervention, and 7 of 22 eyes (32%) lost corrected distance visual acuity (CDVA) of at least one line. Sixteen patients were suitable candidates for additional surgical correction to address these residual visual symptoms and six were not. Thirteen of 22 eyes (59%) received surgical follow- up treatment; nine eyes were treated with contact lenses. After follow-up treatment, six patients (27%) still had a loss of one line or more of CDVA. Three signifi - cant sources of error were identifi ed: errors of cylinder conversion, data entry, and patient identifi cation error. CONCLUSION: Twenty-seven percent of eyes with laser programming errors ultimately lost one or more lines of CDVA. Patients who underwent surgical revision had better outcomes than those who did not. Many of the mistakes identifi ed were likely avoidable had preventive measures been taken, such as strict adherence to patient verifi cation protocol or rigorous rechecking of treatment parameters.