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Patient Harm in Cataract Surgery: A Series of Adverse Events in Massachusetts

Roberto, Sarah A., MPP*; Bayes, Joseph, MD; Karner, Paul E., PhD*; Morley, Michael G., MD, ScM; Nanji, Karen C., MD, MPH§

doi: 10.1213/ANE.0000000000002526
Patient Safety: Brief Report

Massachusetts state agencies received reports of 37 adverse events (AEs) involving cataract surgery from 2011 to 2015. Fifteen were anesthesia related, including 5 wrong eye blocks, 3 cases of hemodynamic instability, 2 retrobulbar hematoma/hemorrhages, and 5 globe perforations resulting in permanent loss of vision. While Massachusetts’ reported AEs likely underrepresent the true number of AEs that occur during cataract surgery, they do offer useful signal data to indicate the types of patient harm occurring during these procedures.

From the *Betsy Lehman Center for Patient Safety, Boston, Massachusetts

Department of Anesthesia, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts

Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts

§Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard University, Boston, Massachusetts.

Published ahead of print October 5, 2017.

Accepted for publication August 16, 2017.

Funding: None.

The authors declare no conflicts of interest.

Reprints will not be available from the authors.

Address correspondence to Karen C. Nanji, MD, MPH, Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114. Address e-mail to

© 2018 International Anesthesia Research Society
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