PURPOSE To characterize surgical confusions in ophthalmology to determine their incidence, root causes, and impact on patients and physicians. DESIGN Retrospective cohort study of errors in ophthalmic surgical procedures between January 1, 2006, and December 31, 2017. PARTICIPANTS One hundred forty-three cases involving surgical confusions. METHODS Cases were identified by the Ophthalmic Mutual Insurance Company from closed case files and by the New York State Health Department from the New York Patient Occurrence Reporting and Tracking program that identified the surgical confusions. MAIN OUTCOME MEASURES Incidence and impact by intended surgery, error type, and root cause as well as preventability by the Universal Protocol. RESULTS Of the 143 cases of surgical confusions identified, 92 cases (64.3%) were deemed preventable by the Universal Protocol. Approximately two thirds, 95 cases (66.4%), were cases of incorrect implants being used during cataract surgery (cataract extraction and intraocular lens implantation), of which 33 cases (34.7%) were not preventable by the Universal Protocol. Wrong eye blocks or anesthesia accounted for 20 cases (14.0%), incorrect eye procedures accounted for 10 cases (7.00%), incorrect refractive surgery measurements accounted for 6 cases (4.20%), incorrect patient or procedure accounted for 5 cases (3.50%), incorrect intraocular gas concentration accounted for 4 cases (2.80%), and incorrect medication in surgery accounted for 3 cases (2.10%). The most common root cause of confusion was an inadequately performed time out, which was responsible for nearly one third of all surgical confusions, 46 cases (32.2%). Incorrect lens orders or calculations before surgery (so-called upstream errors) were the second most common cause of surgical confusion, involving 31 cases (21.7%). The average legal indemnity for incorrect implant during cataract surgery was $57 514 (United States dollars). The average indemnity for incorrect refractive surgery measurement was $123 125, that for incorrect eye procedure was $50 000, and that for incorrect gas concentration was $220 844. CONCLUSIONS Most surgical confusions could have been prevented by following the Universal Protocol properly. However, upstream errors, originating in the clinic or office before surgery, and ineffective communication during time outs suggest a need for modification of the Universal Protocol.

中文翻译：

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眼科手术中的困惑：2006年至2017年的描述，分析和预防错误。

目的描述眼科手术混乱的特征，以确定其发生率，根本原因以及对患者和医生的影响。设计对2006年1月1日至2017年12月31日期间眼科手术程序中的错误进行的回顾性队列研究。参与者143例涉及手术混淆的病例。方法眼科互助保险公司从封闭的病例档案中识别出病例，并由纽约州卫生部门从纽约患者发生情况报告和跟踪程序中识别出手术混乱的情况。主要观察指标：预期手术的发生率和影响，错误类型和根本原因，以及《通用议定书》的可预防性。结果在确定的143例手术混乱中，有92例（64。3％）被《通用议定书》认为是可以预防的。大约三分之二，即95例（66.4％）是在白内障手术（白内障摘除和人工晶状体植入术）过程中使用了不正确植入物的病例，其中33例（34.7％）无法通过《通用议定书》预防。眼球阻塞或麻醉错误占20例（14.0％），眼科手术不正确占10例（7.00％），屈光手术测量不正确占6例（4.20％），患者或手术不正确占5例（3.50％） ），不正确的眼内气体浓度占4例（2.80％），而手术中用药不正确的原因占3例（2.10％）。混乱的最常见根源是执行不充分的超时，这占所有手术混乱的近三分之一，即46例（32.2％）。第二种最常见的手术混乱原因是手术前的镜片订购或计算不正确（所谓的上游错误），涉及31例（21.7％）。白内障手术中不正确植入的平均法律赔偿为57 514美元（美元）。不正确的屈光手术测量的平均赔偿为123 125美元，不正确的眼部手术的平均赔偿为5万美元，而气体浓度不正确的平均赔偿为220 844美元。结论正确遵守《通用议定书》可以避免大多数外科手术的混乱。但是，上游错误（起源于手术前的诊所或办公室）以及超时期间的无效通信表明需要修改《通用协议》。