315 - A Collaborative Journey to Eliminate Wrong Intraocular Lens Implantation
Description: At Kellogg Eye Center/Michigan Medicine the department of Ophthalmology gathered a group of twenty four (24) staff which included Surgery Schedulers, Ophthalmic Techs, Surgical Faculty, Perioperative Nurses, Surgical Technologists, Safety officers and Engineers to address the issue of prevention of wrong implant during cataract surgery. Cataract surgery is the most performed surgery in the United States. It also is the highest reported incidence of incorrect surgery due to wrong intraocular lens (IOL), wrong site. At Kellogg Eye Center/Michigan Medicine they took a collaborative, proactive approach by conducting a risk assessment by using the Healthcare Failure Mode and Effect Analysis (HFMEA) model developed by the VA National Center for Patient Safety in 2002. Two overarching system based actions implemented were: Standard Work process supported by a robust Quality Assurance (auditing vs self reporting) program. The team identified 177 steps and sub-steps in the process from clinic to OR. Of those steps, 36 actions were identified to address 29 vulnerabilities in the process. The team identified the need for standardization due to wide variation found in: Measurement tools/equipment/software in the outpatient clinics, IOL calculations were not always displayed in Kellogg Eye Center Operating Rooms, Communication between surgeon and surgical team varied prior to surgery.The Cataract Protocol Standard Operating Procedure (SOP) created standard work to follow for ophthalmic clinics and Kellogg Eye Center Operating Rooms at Michigan Medicine. The process continues to be audited by a third party outside the Department of Ophthalmology and results posted on a dashboard. The process improved communication and teamwork through conversations between the surgeon and surgical team by discussing the IOL choice prior to surgery. While the SOP did not require the Perioperative Nurse to understand and confirm the calculations; the process did require the Surgical Faculty to walk through the lens choice and rationale for their decision. The process led to trust among the team members and promoted Speaking up for Safety to ensure every patient received the correct IOL at the time of surgery.
Co-Authors: Carol George, Collette Jones, Karen Badyna, Kristen Lemorie