What steps can we take to ensure that we operate on the proper eye and use the proper lens implant? Put another way, how can we reduce or eliminate potential "system error" in cataract surgery? At Premier Eye Care & Surgery, we have developed a 10-step eye identification system that takes into account that medical errors result from a chain of events, not just a single cause, and the elements seldom all come together at the same time. From the pre-operative verification process to marking the surgical site with color-coded stickers, our system actively involves the patient and builds in so many checks that the chance of the wrong-eye and/or wrong-implant surgery is remote.

Use triplicate forms.
To save time, use a triplicate form; you fill it out once and you don't have to fill it out again. Here, you record all the necessary information for cataract surgery: the eye, the implant specifications, pertinent past medical history and a discussion of the risks, benefits and alternatives to surgery. One form goes on the patient's office chart, another is for the surgical chart and the third one is transported with the patient to the operating room. Because what's on the original exam sheet also goes into the OR, none of the information is transferred, lessening the chance the wrong information makes it to the OR.

Use color-coded stickers.
We attach a color-coded sticker (we use Varitronics' Eye-Dentifiers) with this pertinent information (which eye, model and power of lens implant) to the patient's chart. We also hand the patient a second sticker as part of a folder with other take-home information and instruct him to bring it with him the day of the surgery. (Sometimes patients forget, but if they understand that bringing the sticker will help ensure the correct eye is operated on, they are more likely to remember. I carry stickers with me, though, just in case.) Right-eye stickers are round and red and have an R printed on them; left-eye stickers are square and green, with an L. There is space on each sticker to write the lens implant's model and power.

Tell patients to dilate the operative eye.
The patient arrives at the center with the eye dilated as per pre-operative preparation instructions. This lessens the possibility for confusion.

Prepare a master sheet.
Compose a master run-list with all the patients you will operate on that day. The five-column sheet should tell you which eye is to be operated on and the lens' model and power. I bring it along to each site that I operate at that day, be it a hospital or freestanding surgery center.

Use operating schedule as a backup.
The actual operating schedule at each site also includes the eye and lens information, which is called in by my office.

Confirm when patients register.
Instruct your admitting personnel to check the surgery schedule against each patient's consent form, which eye the patient has dilated and the color-coded sticker.

Bring the patient's chart to the OR.
This makes patient information easy to double-check.

Sign the consent form.
Both the patient and physician should do so.

Place sticker on patient's forehead.
While the patient is awake and being prepared for surgery, the physician places the color-coded sticker (which includes side, model and power) on the patient's forehead. (Patients seem to like when the doctor himself places the sticker.)

Call an OR timeout.
Our circulating nurse in the OR reads out loud the patient's name, eye, and the lens model and size. We then check this against the triplicate form, the surgical schedule and the sticker on the patient's forehead.

A small price to pay
Ten steps might sound like a lot, but these are quick and easy to implement - without losing effectiveness. These additions to your pre-surgery routine are a small price to pay to ensure that your patients get the correct lens implant in the correct eye. Besides, the time we save using the triplicate form makes up for any time "wasted" on this system of checks and balances.

You'll find it's easy to tailor these steps to fit your system. The bottom line: This system greatly increases safeguards and significantly decreases the likelihood of wrong-site/wrong-implant surgery.