Serious Reportable Events and Our Commitment to Safety and Quality

Hospital-specific serious reportable events (SREs) for 2008 are now posted on the Department of Public Health’s website. We support and applaud the DPH’s effort to provide transparency. While reports are good, they do not always show the full picture. We thought it would be helpful to provide some context about the reports made by the Massachusetts Eye and Ear Infirmary in 2008.

The Mass. Eye and Ear Infirmary takes its responsibility to report SRE’s very seriously. Patient safety and quality care remain our top priorities. We are committed to implementing national best practices to reduce SRE’s and provide transparency. It should be noted that Mass. Eye and Ear is primarily an ambulatory care and ambulatory surgery facility, and as such the rate of events per 10,000 patient days used in the DPH summary does not reflect the large number of ambulatory and surgical patients we see every day.  We hope that future reports will provide a more meaningful analysis of the rate of serious events at the Mass. Eye and Ear.

The hospital reported four serious reportable events in 2008. Here are details regarding those events.
 
Details/Explanation of the SREs Mass. Eye and Ear Reported in 2008
Surgical SRE (3)
Please note: Correct procedures were performed – incorrect intraocular lens was implanted or incorrect material grafted. The patients suffered no complications or adverse residual effects from the incidents.

Summary: In two cases the incorrect lens was implanted during a cataract operation. The incorrect lens was promptly exchanged for the correct lens without any complications. In one case the incorrect grafting material was used. We found that the process for ordering and verifying the correct intraocular lens/implant was not well defined and developed better systems to prevent future incidents.

More detail: These events are extremely unusual at Mass. Eye and Ear.
A comprehensive investigation and root-cause analysis was conducted and analyzed.
An Action Plan was formulated and implemented.

The root cause analysis revealed that the process for the ordering and verifying of surgical implants/grafts was inconsistently implemented. The Intraocular Lens/Grafting Material Policy was reviewed and revised to include standardization of the process and in-service training was provided to all staff involved in the process.

All surgeons using lens implants must now fax their primary source documents (calculation sheets and physician’s orders) 48 hours prior to the scheduled surgery. Copies of the physician’s order are attached to the implant / grafting material to ensure the lens/ grafting material matches the original physician’s order. Restrictions have been placed on the number of lenses allowed in each case and only the ordered lens/ grafting material for the specific patient is in the OR during the procedure.

Fall SRE (1)
Please note: Patient did not sustain any permanent serious disability resulting from the fall.
Details: The patient was ambulating to the bathroom using a walker and accompanied by a nursing assistant.  The nursing assistant remained with the patient and witnessed the fall. The nursing assistant attempted to break the fall but was unable to do so.  The patient subsequently had evidence of a subarachnoid hemorrhage, for which he was closely monitored and which resolved before discharge.

An internal review took place and no corrective action was deemed necessary regarding the circumstances of the patient fall.  Additionally, the staff was also reeducated on the importance of the Fall Prevention Program.

In conclusion, Mass. Eye and Ear is continuing to monitor the success of these strategies for improvement and is committed to continuous quality improvement. We believe these efforts will prevent future incidents from happening.