title: Patient safety in vitreoretinal surgery: quality improvements following a patient safety reporting system.
abstract: OBJECTIVE
  Vitreoretinal (VR) surgery is complex. Most clinical conditions that VR surgeons manage have a high risk for blindness or severe visual impairment. Reporting of patient safety incidents (PSI) in VR surgery was introduced at the Moorfields Eye Hospital (MEH) in the 1990s. We examine the role of PSI reporting in making VR surgery safer at our institution.
  
  
  METHODS
  Qualitative review of PSIs from 1997 to 2009 at MEH, London, UK.
  
  
  RESULTS
  Over the 13-year study period, 38 789 VR procedures were undertaken and 579 VR PSIs occurring in theatre or inpatient were reported. Mean rate of PSI reporting was 1.49% (range 0.12-3.35). In comparison, the mean rate of PSI reporting over the same period across all National Health Service ophthalmology in England was 0.59% (range 0.36-0.49). Overall, 0.9% of VR PSI resulted in 'Severe' harm, 11.6% in 'Moderate' harm and 87.5% in 'No' or 'Low' harm. 15 (2.6%) of PSIs directly resulted in a change in clinical practice, 13 of which occurred in the first half of the study period. 12 (3.6%) critical incidents were violations of pre-existing protocols and guidelines, eight of which occurred in the second half of the study period. 61 (10.9%) of PSIs fell into nine main error subtypes that contributed to a change in practice. The most common were ocular hypotony (2.9%), medical device failure (2.8%) and delay in VR surgery (1.2%).
  
  
  CONCLUSIONS
  VR PSI reporting resulted in a change in clinical practice. Longitudinal analysis suggests an accompanying increase in patient safety.
authors.affiliation: Department of Vitreoretinal Surgery, Moorfields Eye Hospital, City Road, London EC1V 2PD, UK. chien.wong@moorfields.nhs.uk
authors.forename: S Chien
authors.initials: SC
authors.lastname: Wong
authors.forename: Simon P
authors.initials: SP
authors.lastname: Kelly
authors.forename: Paul M
authors.initials: PM
authors.lastname: Sullivan
mesh_terms: D006801:Humans; D019300:Medical Errors / Q000706:statistics & numerical data*; D061214:Patient Safety / Q000592:standards*; D058996:Quality Improvement; D019984:Quality Indicators, Health Care; D012189:Retrospective Studies; D017751:Safety Management / Q000379:methods*; D006113:United Kingdom; D057586:Vitreoretinal Surgery / Q000592:standards*