Wrong-Site Surgery in Pediatric Ophthalmology

Purpose: To determine the prevalence of pediatric ophthalmologists who have performed wrong-site surgery, propose risk factors leading to these errors, and assess the effectiveness of the Universal Protocol in preventing them.

Methods: Approximately 1,000 pediatric ophthalmology surgeons were invited to complete an anonymous 10-question survey. Respondents were divided into two groups: those who performed or attempted wrong-site surgery (wrong-site surgery group) and those who had never performed a wrong-site surgery (intended surgical site group). The risk factors (ie, marking procedure, years in practice, surgical experience, adherence to the Universal Protocol time-out, and operating room factors) were compared between groups.

Results: Of the 156 respondents, 56.4% never performed, 9% attempted, and 34.6% performed a wrong-site surgery. The use of any procedure to mark the eye decreased the likelihood of a wrong-site surgery by 61% (odds ratio [OR] = 0.39; P = .069). A lower likelihood of error occurred when a single individual led the time-out and multiple individuals participated in checking the accuracy of the time-out. Surgeons in practice for less than 15 years had a lower likelihood of performing a wrong-site surgery (OR = 0.37; 95% confidence interval [CI] = 0.19 to 0.72; P = .003). Factors not significantly associated with wrong-site surgeries were the number of surgeries performed per year (OR = 0.66; 95% CI = 0.35 to 1.24; P = .20) and the number of operating rooms used.

Conclusions: In concordance with previous reports of other surgical specialties, self-reported error in pediatric ophthalmology is not uncommon. This study highlighted important practices that can be easily adopted by surgeons to decrease the likelihood of wrong-site surgeries. First, marking the surgical site must be part of the preoperative preparation. Second, a single designated individual should lead the time-out and the surgeon should be directly involved in all steps of the time-out process. Third, surgeons who have been in practice for more than 15 years may require additional safeguards to ensure that the correct surgery is performed and to monitor their complacency. [J Pediatr Ophthalmol Strabismus. 2018;55(3):152-158.].