Patients recently experienced errors during cataract surgery in Massachusetts, such as

• Implantation of the wrong lens
• Surgery on the wrong eye or, in one case, the wrong patient
• Eye block complications leading to blindness in one eye

Among the contributing factors were

• Lack of standardization within a facility, from lens ordering to surgical site marking procedures
• More than one lens in the operating room
• Incomplete or inadequate "time outs"
• Issues related to safety culture

Clinicians involved in cataract errors thought their practices were safe

In the words of one operating room nurse a facility reporting an error:

"How could this have happened [here]?"

"We are all right on top of it ... We are very, very careful."

Panel recommendations include

• 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

As a result of the panel's work

• 90 percent of cataract surgeons in the state responding to a survey said the recommendations were useful
• 40 percent of the same group reported changing some of their practices in light of the panel's findings
• A leading national journal for anesthesiologists drew attention to anesthesia practices in eye surgery, publishing two articles on the Center's expert panel findings and an editorial.