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Corneal Abrasion Injuries
 Pa Patient Saf Advis 2009 Dec;6(4):144. 
 

In response to an inquiry by a Pennsylvania healthcare facility Patient Safety Officer, staff from the Pennsylvania Patient Safety Authority identified 231 reports that indicated corneal abrasions had occurred between June 2004 and August 2009. Corneal abrasion is the most common ocular injury occurring in the perioperative period.1 Most of the Authority reports (81%) were recognized in the perioperative setting. However, 19% of the reports occurred in diverse care areas such as the medical intensive care unit, the emergency department, on telemetry floors, in radiation oncology, and in labor and delivery wards, leading to the conclusion that all staff should be able to quickly identify, report, and treat corneal abrasions.

See Tables 1 and 2 for the number of reports received by the Authority.

Table 1. Reports Submitted by Year

  Table 1. Reports Submitted by Year

 

 

 Table 2. Corneal Abrasions by Event Type (Actual Reports June 2004 to August 2009)
  Table 2. Corneal Abrasions by Event Type (Actual Reports June 2004
  to August 2009)






Closed claims analysis in 2006 from two major anesthesia-related malpractice databases showed that ocular injuries, in general, account for 3% to 8% of anesthesia-related malpractice claims.2 In 2007, Agency for Healthcare Research and Quality national statistics showed superficial corneal injuries occurred in approximately 1.5% of all hospital discharges; however, not all of these cases represent iatrogenic injuries because some may have been present on admission.3

The lack of information about corneal abrasions prevents the Authority from making new insights about this problem. Reports that are more detailed might be helpful in determining how and why these injuries occur.

Notes

  1. Mecca RS. Postoperative recovery. In: Barash PG, Cullen BF, Stoelting RK, eds. Clinical anesthesia 4th ed. Philadelphia (PA): Lippincott Williams & Wilkins; 2001:1396.
  2. MacRae MG. Closed claims studies in anesthesia: a literature review and implications for practice. AANA J 2007 Aug;75(4):267-75.
  3. United States Department of Health and Human Services. Agency for Healthcare Research and Quality. 2007 national statistics (918.1 superficial injury to the cornea) [online]. [cited2009 Sep 4]. Available from Internet: http://hcupnet.ahrq.gov/HCUPnet.jsp.
 
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THE PENNSYLVANIA PATIENT SAFETY AUTHORITY AND ITS CONTRACTORS  
PSA LOGO The Pennsylvania Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (“Mcare”) Act. Consistent with Act 13, ECRI Institute, as contractor for the Authority, is issuing this publication to advise medical facilities of immediate changes that can be instituted to reduce Serious Events and Incidents. For more information about the Pennsylvania Patient Safety Authority, see the Authority’s Web site at www.patientsafetyauthority.org .      
ECRI LOGO ECRI Institute, a nonprofit organization, dedicates itself to bringing the discipline of applied scientific research in healthcare to uncover the best approaches to improving patient care. As pioneers in this science for more than 40 years, ECRI Institute marries experience and independence with the objectivity of evidence-based research. More than 5,000 healthcare organizations worldwide rely on ECRI Institute’s expertise in patient safety improvement, risk and quality management, and healthcare processes, devices, procedures and drug technology.      

ISMP Logo The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication error prevention and safe medication use. ISMP provides recommendations for the safe use of medications to the healthcare community including healthcare professionals, government agencies, accrediting organizations, and consumers. ISMP’s efforts are built on a nonpunitive approach and systems-based solutions.      
 
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