title: Sources of medical error in refractive surgery.
abstract: OBJECTIVE
  To evaluate the causes of laser programming errors in refractive surgery and outcomes in these cases.
  
  
  METHODS
  In this multicenter, retrospective chart review, 22 eyes of 18 patients who had incorrect data entered into the refractive laser computer system at the time of treatment were evaluated. Cases were analyzed to uncover the etiology of these errors, patient follow-up treatments, and final outcomes. The results were used to identify potential methods to avoid similar errors in the future.
  
  
  RESULTS
  Every patient experienced compromised uncorrected visual acuity requiring additional intervention, and 7 of 22 eyes (32%) lost corrected distance visual acuity (CDVA) of at least one line. Sixteen patients were suitable candidates for additional surgical correction to address these residual visual symptoms and six were not. Thirteen of 22 eyes (59%) received surgical follow-up treatment; nine eyes were treated with contact lenses. After follow-up treatment, six patients (27%) still had a loss of one line or more of CDVA. Three significant sources of error were identified: errors of cylinder conversion, data entry, and patient identification error.
  
  
  CONCLUSIONS
  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.
authors: University of Utah, Salt Lake City, Utah 84132, USA. majid.moshirfar@hsc.utah.edu
authors: Majid
authors: M
authors: Moshirfar
authors: Rachel G
authors: RG
authors: Simpson
authors: Sonal B
authors: SB
authors: Dave
authors: Steven M
authors: SM
authors: Christiansen
authors: Jason N
authors: JN
authors: Edmonds
authors: William W
authors: WW
authors: Culbertson
authors: Stephen E
authors: SE
authors: Pascucci
authors: Neal A
authors: NA
authors: Sher
authors: David B
authors: DB
authors: Cano
authors: William B
authors: WB
authors: Trattler
mesh_terms: D000328:Adult; D019781:Corneal Topography; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D006956:Hyperopia / Q000503:physiopathology / Q000601:surgery*; D020731:Keratomileusis, Laser In Situ / Q000706:statistics & numerical data*; D054018:Lasers, Excimer / Q000009:adverse effects*; D008297:Male; D019300:Medical Errors / Q000706:statistics & numerical data*; D008875:Middle Aged; D009216:Myopia / Q000503:physiopathology / Q000601:surgery*; D018903:Photorefractive Keratectomy / Q000706:statistics & numerical data*; D012029:Refraction, Ocular / Q000502:physiology; D012086:Reoperation; D012189:Retrospective Studies; D012984:Software; D014786:Vision Disorders / Q000209:etiology* / Q000503:physiopathology / Q000601:surgery; D014792:Visual Acuity / Q000502:physiology