Dear Readers,

Patient safety is a global imperative. It has extensive implications for all WHO Members states, for all health-care workers and for all of us when we become patients. We already know that about 10% of people who receive health care in industrialized countries will suffer because of preventable harm and adverse events.

This Sitenews uses a general approach to the understanding of patient safety and how to avoid medical errors in the field of ophthalmology and general. This issue introduces you to the Surgical confusion, Patient safety incidents, Clinical errors, Infection which will enable readers to understand the problems related to Patient safety.

The organization, which we are featuring is WHO Patient Safety, is helping to bring to the forefront the voices of patients suffering from the consequences of resistant pathogens, with the aim of raising awareness about this serious problem and the will for such harm to be avoided worldwide.

The featured personality is Professor Bill Runciman, President of the Australian Patient Safet Foundation

We wish you an experience of learning that is very practical. Your feedback will help us to improve.

Please send in your feedback at eyesite@aravind.org

Library Team
The Issue Features...
Volume 6 & 7,Issue 12 & 1,December 2010 & January 2011
•   Introduction
•   Surgical Confusion
•   Patient Safety Incident
•   Clinical Governance
•   History of Patient Safety
•   Organization
•   Personality
•   Conclusion
•   Talk to Us
•   Past Issues


The safety of patients places the prime responsibility for adverse events on deficiencies in system design, organization and operation rather than on individual practitioners or products. For those who work on systems, adverse events are shaped and provoked by upstream systematic factors, which include the particular organizations strategy, culture, working practices, approach to quality management, risk prevention and capacity for learning from failures. Countermeasures based on changes in the system are, therefore, more productive than those that target the behavior of individuals and their propensity to omit errors.

World Alliance for Patient Safety - WHO draft guidelines for adverse event reporting and learning systems

The objective of these draft guidelines is to facilitate the improvement or development of reporting systems that receive information which can be used to improve patient safety. The target audience is countries, which may select, adapt or otherwise modify the recommendations to enhance reporting in their specific environments and for their specific purposes. The guidelines are not meant to be an international regulation and will undergo modification over time as experience accumulates.


  • Surgical Confusions in Ophthalmology

  • To investigate the hypothesis that surgical confusions rarely occur but are unacceptable to the public; occur in predictable circumstances; involve a wrong lens implant more often than a wrong eye, procedure, or patient; and can be prevented using the Universal Protocol.

  • Eliminating Wrong Site Surgery

  • Wrong-site surgery is a problem that occurs across surgical specialties, and is usually caused by a breakdown of the system or lack of a system to verify the site of surgery.

  • Cut the Risk of Wrong-Site Surgery

  • Wrong-site surgery may be uncommon in ophthalmology, but as J. Robert Rosenthal, MD, said, If theres one wrong-site surgery, thats one too many. When the Academy issued its Patient Safety Bulletin on the topic, it acknowledged that these errors occur on a rare basis in ophthalmology, but also noted that the consequences could be visually devastating, and thus, measures should be taken to eliminate their possibility.

  • Minimizing Wrong IOL Placement

  • After cataract surgery, patients often expect excellent visual acuity without needing glasses. If the IOL implanted does not meet their visual acuity expectations, additional postoperative correction, possibly even a subsequent procedure to exchange the IOL, may be required. But, in reality, the patient often needs minimal eyeglass correction to obtain maximum visual acuity after eye surgery. Although rare in occurrence, one error that can occur is the insertion of an incorrect intraocular lens (IOL) in cataract surgery. The IOL can be the wrong power, wrong size or wrong type, which can lead to postoperative refractive errors and less satisfactory vision for the patient.3 The surgeon is ultimately responsible for assuring that the correct lens is placed at the time of surgery.


  • Wrong intraocular lens implant; learning from reported patient safety incidents

  • This article focuses on wrong intraocular lens (IOL) implant events in cataract surgical care reported through a national incident reporting database.

    a) THEATRE

  • Patient Safety in the Operating Room

  • This article analyses the issues related to patient safety in operating rooms and details the reasons for the same. It discusses the so called OR culture as the biggest challenge to patient safety. The need for building up a rapport among the clinicians and support staff is elaborated.

  • Advances in patient safety: non-technical skills in surgery

  • Patient safety problems occur across healthcare but there are particular risks in surgery and surgical patients are involved in as many as 45% of medical adverse events. Non-technical skills (e.g. leadership, decision making, assertiveness, team co-ordination) are responsible for maintaining safety. Surgeons non-technical skills play an equally significant role in patient safety in the intraoperative environment. An attitude survey was carried out with 352 theatre staff from 17 hospitals in Scotland (involving consultant surgeons, trainee surgeons and theatre nurses) to look at opinions and practice relating to non-technical skills and safety. Respondents generally demonstrated positive attitudes to behaviours associated with effective teamwork and safety. Attitudes indicating a belief in personal invulnerability to stress and fatigue were evident in both nurses and surgeons. Consultant surgeons had more positive views on the quality of surgical leadership and communication in theatre than trainees and theatre nurses.

  • Monitored anaesthesia care (MAC) and ophthalmic surgery BK Bhattarai

  • The use of monitored anaesthesia care (MAC) is increasing with the discovery of newer, more effective and appropriate drugs and techniques. MAC is intended to achieve patient comfort with safety and optimal clinical outcome and is being extensively used worldwide for cataract and other ophthalmic surgeries. This article briefly reviews the conceptual basis of MAC, its use in ophthalmic surgeries, sedative-analgesic drugs commonly used during MAC in eye surgeries, monitoring during MAC in eye surgery and the role of anaesthesia practitioners during MAC.

  • The Value of Routine Preoperative Medical Testing before Cataract Surgery

  • Routine preoperative medical testing is commonly performed in patients scheduled to undergo cataract surgery, although the value of such testing is uncertain. We performed a study to determine whether routine testing helps reduce the incidence of intraoperative and postoperative medical complications.


  • Minimizing Medication Errors: Communication about Drug orders.( Patient Safety Bulletin Number 3)

  • This bulletin lists out the common factors that contribute to medication errors and suggestions for improving patient safety.

  • Successful remediation of patient safety incidents: A tale of two medication errors

  • This study was to identify key features of successful remediation efforts that accompany the proactive disclosure of medical errors to patients.


  • Guidance on patient safety in ophthalmology from the Royal College of Ophthalmologists.

  • Royal College of Ophthalmologists has provided guidance to improve ophthalmic patient safety, and is presented in this paper. Which patient safety incidents to report and analyze in ophthalmic practice are outlined and how to do so is also discussed.

  • A pilot study in ophthalmology of inter-rater reliability in classifying diagnostic errors: an under investigated area of medical error.

    This article focused on how to evaluate the applicability and reliability of three classification systems for misdiagnosis.

  • Quality of medical care and surgical patient safety: medical error, malpractice and professional liability

  • Quality of medical care includes different areas: opportunity, professional qualifications, safety, respect for ethical principles of medical practice and satisfaction with care outcomes. In this regard, at CONAMED (National Commission for Medical Arbitration), 8062 complaints were followed, analyzed and completed between June 1996 and December 2008: in 16.8% of the complaints there were insufficient data to determine whether or not there was evidence of malpractice; 20.8% of the complaints had evidence of malpractice and in 62.4% of complaints the existence of good practice was determined according to the lex artis. Among the surgical specialties with the highest malpractice cases were the following: general surgery, gynecology, orthopedics, ophthalmology, emergency surgery, urology and traumatology. Acknowledgment of the concept of quality of health care provides a starting point to determine the source of errors, malpractice and professional responsibility in order to resolve and prevent them. CONAMED offers alternative means for conflict resolution related to physician-patient relationship by means of conciliation and arbitration, favoring patient and family, as well as the medical profession.

  • Medical Errors and Patient Safety

    The purpose of this Curriculum guide is to address this glaring deficit in medical education. We hope we can encourage and support a significant increase in the education about, and discussion of, PATIENT SAFETY AND MEDICAL ERROR in medical schools and residencies.

  • E-Prescribing: Improve Profits, Increase Productivity, and Deliver Better Patient Care

  • E-prescribing enables eyecare professionals (ECPs) to transmit prescriptions or prescription-related information through electronic media. There are two types of qualified e-prescribing systemsa standalone system or an Electronic Health Records (EHR) system with an e-prescribing function. There are a number of ways that e-prescribing improves efficiency. E-prescribing will also help you keep your patients safe by alerting you to duplicate drug therapy or potential drug interactions. It can also help you check on your patients compliance.

  • Practical ophthalmic procedures vol. 1 teaching set

  • This guide explained the Ophthalmic procedures including cleaning of eyelids, installing eye drops, applying eye ointment, taping an eyelid closed, applying an eye pad and eye shield, making an eye shield, and how to apply an eye bandage.

  • Preventing Surgical Confusions in Ophthalmology (An American Ophthalmological Society Thesis)

    This study was designed to estimate the incidence of surgical confusions in ophthalmology, to assess factors contributing to their occurrence, to discover their consequences to both patients and ophthalmologists, and to examine the potential effectiveness of the Universal Protocol in their prevention.

  • d) WARD and DAYCARE

  • Ophthalmic Daycare and Inpatient Facilities

    Day care is increasingly being used for other ophthalmic procedures including vitreo-retinal surgery. As many eye diseases are age related, demographic changes are also likely to be responsible for increased activity in eye departments -as the proportion of elderly people in the general UK population increases-, as new techniques are being developed for such patients and as the threshold for surgery reduces.

    Day care is essential to understand that satisfactory, safe day surgery care requires very careful organisation and planning. The following points are particularly important: Patient perspective, Patient care pathway, Level and type of activity, Equipment, Staffing the ophthalmic ward/day unit, Inpatient facilities and patient safety.

  • Post Operative Care in Cataract

    This write up focused on the precautions to be taken after surgery, how to apply the eye drops and how to apply eye ointment.


  • Control of Infection in Ophthalmic Practice: Risk reduction principle

    This small article focuses on how to control of infection in ophthalmic hospitals.


  • Patient Safety in Ophthalmology

  • Clinical or organisational errors, incidents and complications will happen often. Such events provide a rich opportunity for learning, if properly considered. Actions resultantly taken may reduce the risk of similar events recurring. As under reporting of incidents is commonplace, clinicians need to overcome barriers to incident reporting. The college provides guidance herein on clinical governance in ophthalmology and on reporting and analysing ophthalmic patient safety incidents.

  • The How to guide for Reducing Harm from Falls

  • This document is aimed at managers and teams involved in leading and implementing changes to reduce harm from falls.

  • How to Manage Your Malpractice Risks

  • Ophthalmology thought leaders and malpractice defense attorneys say protocols and checklists, good informed consent, attentiveness to patients' complaints and diligent documentation of your care can spare you the misery of a malpractice claim, or at least provide a credible defense if that claim goes forward. hen an error does occur, how you handle it postoperatively can alter the patient's attitude about pursuing a malpractice claim.


  • History of Patient Safety

  • Patient safety is a new healthcare discipline that emphasizes the reporting, analysis, and prevention of medical error that often lead to adverse healthcare events. The frequency and magnitude of avoidable adverse patient events was not well known until the 1990s, when multiple countries reported staggering numbers of patients harmed and killed by medical errors. Recognizing that healthcare errors impact 1 in every 10 patients around the world,the World Health Organization calls patient safety an endemic concern.[1] Indeed, patient safety has emerged as a distinct healthcare discipline supported by an immature yet developing scientific framework. There is a significant transdisciplinary body of theoretical and research literature that informs the science of patient safety.



  • WHO focuses on new resources on patient safety, classification system, videos, case studies, and learning from error, patient safety solution survey and etc.,


Professor Bill Runciman

Bill has been President of the Australian Patient Safety Foundation since its inception in 1988, when, together with anaesthesia colleagues, he conceptualised and implemented AIMS in the form of a nation-wide paper-based anaesthesia incident monitoring project. Since then he has provided leadership and made fundamental contributions to patient safety and quality research both in Australia and internationally. Bill was concurrently the Foundation Professor of Anaesthesia and Intensive Care at the University of Adelaide and Head of Department at the Royal Adelaide Hospital from 1988 to 2007. He was a member of the Australian Council for Safety and Quality in Health Care and of the Australian Health Information Council.

In 2007, Bill was appointed as a Professorial Research Fellow in Patient Safety at the Joanna Briggs Institute of University of Adelaide and Royal Adelaide Hospital. He also held appointments as an Adjunct Professor, Human Factors in Healthcare, at the University of South Australia and a Visiting Professor in Change Management at the Centre for Clinical Governance Research in Health, Faculty of Medicine, University of New South Wales. Currently Bill is Professor of Patient Safety & Healthcare Human Factors, School of Psychology, Social Work & Social Policy, University of South Australia, Professorial Research Fellow for the Joanna Briggs Institute, Royal Adelaide Hospital and Visiting Professor, Australian Institute of Health Innovation, University of NSW. Bill was a co-author of the landmark Quality in Australian Health Care Study published in the Medical Journal of Australia (MJA) in 1995, one of the top 10 cited studies published in the MJA.

Bill has been involved in the publication of over 200 scientific papers and chapters and has given over 600 lectures by invitation. In 2007, he published the patient safety textbook: Runciman B, Merry A, Walton M, 'Safety and Ethics in Healthcare: a Guide to Getting It Right', Ashgate, Aldershot, 2007. In 2007, Bill was awarded the Pugh Award of the Australian Society of Anaesthetists in recognition of his outstanding contribution to the science of anaesthesia, intensive care or related disciplines. In 2008, Bill was also awarded the Sidney Sax Medal of the Australian Healthcare and Hospitals Association for outstanding contribution in the field of health services policy, organization, delivery and research.


Every health system in the world has the opportunity to make care for the patients it treats safer. The first step is to secure the commitment of political leaders, health policy makers and the main professional bodies in each country to the goal of safer care. With the addition of technical support, skilled leadership of health organizations and the input of patients and consumers there will be an unstoppable global movement for patient safety that will save many lives and prevent much serious harm. Todays reality is that the risks of health care are far too high compared with other potentially high-risk industries that have much better safety improvement records. Tomorrows dream is that commitment to patient safety will save lives and prevent harm across the whole world.


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