Sources of Medical Error in Refractive Surgery

Abstract

Twenty-seven percent of eyes with laser programming errors ultimately lost one or more lines of CDVA. Patients who underwent surgical revision had better outcomes than those who did not. Many of the mistakes identified were likely avoidable had preventive measures been taken, such as strict adherence to patient verification protocol or rigorous rechecking of treatment parameters.

Biomechanical and optical behavior of human corneas before and after photorefractive keratectomy

“…1 Nevertheless, additional predictive tools based on numerical models of the eye that simulate different phases of surgery can be useful to the surgeon, in particular for corneas with topography anomalies and irregularities. 2 approximately 16 mm Hg) and record the corneal deformation resulting from the application of brief, localized air pressure. The knowledge of the mechanical response of the cornea to known actions, for example in the form of a sequence of images reproducing different phases of the deformation, is fundamental for the calibration of advanced material models that describe the micromechanical structure of the stroma.…”

Errors in Treatment of Lower-order Aberrations and Induction of Higher-order Aberrations in Laser Refractive Surgery

“…The largest published case series specifically addresses medical error in refractive surgery and identifies specific steps where this occurred in 18 patients. 36 Only two other case reports describing errors in data entry in 4 eyes have been reported in the English literature. 37,38 For this reason, it is difficult to know the incidence of these events, though extrapolating from internal data, Moshirfar et al estimated that 280 to 400 cases of data entry errors in refractive surgery occur annually.…”

“…37,38 For this reason, it is difficult to know the incidence of these events, though extrapolating from internal data, Moshirfar et al estimated that 280 to 400 cases of data entry errors in refractive surgery occur annually. 36 Regardless of the actual incidence, the time period from when a surgeon first meets a patient for a screening examination to the application of the laser contains numerous opportunities for incorrect data entry or transfer.…”

Advances in Refractive Surgery

“…3 Medical errors plague every specialty of medicine, resulting in a possible devastating impact on the patient. Moshirfar et al 4 performed a multicenter retrospective review, identifying 22 eyes of 18 patients who had errors in the preoperative planning. These errors led to an inaccurate entry into the laser programming software.…”