Cataract Report Cover

Report and recommendations
Executive summary

Advancing Patient Safety in Cataract Surgery

Though cataract removal is considered among the safest and most common procedures performed in the U.S., errors during cataract surgery in persist. During 2014 and 2015, facilities in Massachusetts reported 16 Serious Reportable Events (SREs) related to cataract surgery to the Department of Public Health. Five of these "never events" caused permanent loss of vision and others required patients to postpone the procedure or undergo corrective surgery. 

The Betsy Lehman Center convened an expert panel of ophthalmologists, anesthesiologists, nurse managers and patient representatives to more closely examine the risks surfaced by these incidents and to develop recommendations for mitigating them. 

Panel recommendations:

  • Use multiple, unique patient identifiers
  • Use uniform procedures for managing lenses and marking operative eye
  • Improve time-out practices and onboarding of contracted staff
  • Use the least invasive form of anesthesia appropriate for the patient
  • Engage patients in decisions about anesthesia and sedation


The safe cataract surgery toolkit includes IOL verification protocols, surgical checklists, patient decision aids, and more

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Peer-reviewed articles

Preventing Adverse Events in Cataract Surgery (Narrative review article)

Patient Harm in Cataract Surgery (Brief report)


OpenAnesthesia talks to expert panel co-chair Dr. Karen C. Nanji

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