An expert panel makes recommendations. Then what happens?

In 2015, the Betsy Lehman Center convened an expert panel to take a careful look at a select set of cases where patients were harmed during cataract surgery in Massachusetts in recent years. The panel issued recommendations to improve the safety of care in these common outpatient procedures. To learn more about the impact of the panel’s work, the Center — in close partnership with the Massachusetts Society of Eye Physicians and Surgeons — surveyed eye physicians in the state. 

Click on the photos below to see highlights from the survey.

  • Why focus on patient harm in cataract surgery?

    Every year, the state receives reports of more than 1,000 serious reportable events (SREs) from hospitals and ambulatory surgery centers, and providers have asked the state to share analysis, event details, and corrective measures taken by peer institutions to prevent recurrence. In 2014, 13 percent of surgical SREs reported occurred to patients undergoing cataract surgery, the most common surgical procedure in the U.S. As a result, we convened an expert panel of providers and patients to look into why these errors occurred and what could be done to prevent more of them. Read the panel’s full report here.

  • Is the panel’s work having an impact?

    Early results are encouraging. Over 40 percent of Massachusetts cataract surgeons surveyed acted on the panel’s recommendations and more than 75 percent of surveyed ophthalmologists found the panel’s findings to be “somewhat” or “mostly” consistent with their own observations and experience. View the full survey results here. Not everyone agreed with the panel’s conclusions, particularly around choice of anesthesia technique. And responses to surveys are not as reliable as measuring outcomes. We may not know the real impact of the panel’s work for some time.

Read the panel’s report and recommendations.

Want to know more about the panel’s work? Click on the arrow next to each question below to see a short answer.

  • What can I learn about patient safety from this initiative if I’m not involved in cataract surgery?

    Here are a few takeaways that will inform our work going forward and may help you in yours:

    1) We can learn from imperfect data: Serious Reportable Events (SREs) are under-reported in Massachusetts. But unlike other datasets that are more complete, these reports offer narratives that describe how and why adverse events occurred. Expert review of these narratives can help highlight where risks exist and how providers can address them. You can do the same in your organization even if the data are limited.

    2) Stories from peers are persuasive: We conducted a series of confidential conversations with cataract surgery providers who had experience with adverse events. All were deeply affected and eager to share with others what they had learned. Leverage the experience of people in your organization to ‘spread the word’ about how, what and why to make changes in their approaches to patient care to improve safety.

    3) Share safety messages via many channels and in many formats: Information won’t have much influence if the target audience doesn’t read it. Health care staff get their information in a variety of ways and we continue to share the report’s findings with providers through peer-reviewed journal articles, the Web, mainstream media outlets, Grand Rounds presentations, targeted mailings and online webinars.

    4) Providers need more than information—they need tools to act: We compiled relevant tools from across the country to help cataract surgery practices implement the panel’s recommendations. Add tools staff can use to any patient safety improvement project you undertake.

    5) Involve patients in safety improvement work: Patient representatives were critical to our expert panel’s function and perspective. Consider involving patients in your safety planning and discussions. They can be among your greatest assets.

Go back to cataract surgery initiative main page.


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