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Ophthalmology Safety Checklist :. Improving Patient Safety- One Step at a Time . Donna U. Gramigna, RN, BSN, CPN(C) Hamza Khan, MD, MPH FRCSC FACS Courtney Addis, RN, BScN, MHSA Carla Service, BScN, MPA, CHE. Financial Disclosures.

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Ophthalmology safety checklist

Ophthalmology Safety Checklist:

Improving Patient Safety- One Step at a Time

Donna U. Gramigna, RN, BSN, CPN(C)


Courtney Addis, RN, BScN, MHSA

Carla Service, BScN, MPA, CHE

Financial disclosures
Financial Disclosures

  • Donna Gramigna, RN, BSN, CPN(C):Has no financial interest.

  • Hamza N Khan, MD, MPH FRCSC FACS:



    Bausch and Lomb

  • Courtney Addis, RN, BScN, MHSA:

    Has no financial interest.

  • Carla Service, BScN, MPA, CHE:Has no financial interest.


Surgical safety is a priority across health systems and for all providers. Utilizing a perioperative checklist may reduce the rate of certain ‘never events’1 such as wrong patient, wrong site, or wrong implant surgery. We found the development of a specific Ophthalmology checklist tool required an interdisciplinary approach.


  • WHO sponsored Surgical Checklist study demonstrated a 50% reduction in perioperative morbidity in 8,000 cases across 7 countries in 3 continents.2Related studies have shown the use of preoperative checklists reduced failures in communication by enhancing effective teamwork. 2, 3A majority of errors in Cataract surgery may be prevented by the use of a pre-operative Time-Out.

  • The original WHO Checklist does not capture common ophthalmology outcomes and includes several items not applicable.

  • The use of surgical checklist is supported by Accreditation Canada.

  • The WHO checklist was already being used in the organization’s main operating rooms.


  • Specific needs in Cataract surgery were identified by an interdisciplinary working group (Surgeons, Nurses, QI Consultants, and OR Manager).

  • An environmental scan was done of ophthalmology adaptations of the WHO checklist - including sites across Canada, United States, United Kingdom, and India.

  • The new tool was developed around the existing Time-out function which was already in use. (See Fig. 1 for details.)

Methods cont
Methods (cont.)

  • Target:

    Primary goals: patient safety and good team communication

    Secondary goal: minimal impact on the high volume, rapid turnover setting of outpatient cataract surgery

  • Review by surgical and nursing staff for further input prior to implementation.

  • Data collection: Pre- and post-implementation reporting of significant incidents and “near misses”; opinion survey of team members on utility, impact on safety, team communications, and ease of use (Fig. 3).

Figure 1 evolution of the checklist
Figure 1: Evolution of the Checklist

The New Safety Checklist

The Time-Out Poster


  • Significant education was needed to implement the tool. One case of wrong intraocular lens (IOL) was reported in both periods pre- and post-implementation. No statistical reduction in wrong IOL implants was seen. Staff reported better communication, including several near-misses, as indicated by 28% of the survey respondents (Fig. 3). Education and engagement of the entire surgical team resulted in better communication and workflow. Reports of near-miss incidents indicate that the tool is effective in reducing adverse events.

  • Engagement of all front-line staff and scan of existing procedures allowed for a rapid and successful development of a specific checklist tool for cataract surgery.

Figure 3 results of team survey questions
Figure 3: Results of team survey questions.


  • A low rate of ‘never events’ was reported

  • Staff reports of ‘near-misses’ suggest the Checklist can improve patient safety

  • The tool can improve team communication

  • An Ophthalmology Checklist should be a standard of practice


  • Simon JW, Ngo Y, Khan S, Strogatz D. (2007) Surgical Confusions in Ophthalmology. Archives of Ophthalmology, 125:1515-1522.  

  • Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AS, Dellinger EP, Herbosa T, Joseph S, Kibatala PL, Lapitan MCM. Merry AF, Moorthy K, Reznick RK, Taylor B, & Gawande A. (2009). A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population. New England Journal of Medicine, 360(5):491-9.  

  • Lingard L, Regehr G, Orser B, et al. (2008)  Evaluation of a Preoperative Checklist and Team Briefing Among Surgeons, Nurses, and Anesthesiologists to Reduce Failures in Communication. Archives of Surgery, 143: 12-8.

  • Russo, C., Owens, P., Steiner, C. & Josephsen, J. (2007). Ambulatory Surgery in US Hospitals 2003. Agency for Healthcare Research and Quality.  

  • Canadian Ophthalmological Society (2010). COS Statement on Value for Uninsured Services in Canada. Retrieved May 2010 from: www.eyesite.ca .