An observational study of laterality errors in a sample of clinical records

• Published in: Eye (London) Vol. 22; no. 3; pp. 340 - 343
• Main Authors: ElGhrably, I, Fraser, S G
• Format: Journal Article
• Language: English
• Published: London Nature Publishing Group UK 01-03-2008; Nature Publishing Group
• Subjects: Biological and medical sciences; clinical-study; Handwriting; Humans; Laboratory Medicine; Medical Errors - prevention & control; Medical Errors - statistics & numerical data; Medical Records - standards; Medical sciences; Medicine; Medicine & Public Health; Miscellaneous; Ophthalmologic Surgical Procedures - adverse effects; Ophthalmology; Pharmaceutical Sciences/Technology; Practice Guidelines as Topic - standards; Preoperative Care - adverse effects; Risk Management; Surgery; Surgical Oncology; United Kingdom; transposition errors; patient safety; ophthalmology; wrong site surgery; laterality; Human; Observational study; Toxicity; Surgical transfer; Error; Treatment; Surgery; Ophthalmology; Safety; Laterality
• ISSN: 0950-222X; 1476-5454
• DOI: 10.1038/sj.eye.6702590

Background
Confusing left with right eyes can have a potentially serious adverse outcome. The most extreme occurrence is wrong site surgery but even potentially less serious errors can undermine patient confidence in their medical care. This study was designed to look into how often this could be detected in clinical notes.
Methods
An observational study conducted in an ophthalmic hospital. Hundred patients were randomly selected and their clinical notes retrieved. Notes were analysed for the number of left/right transpositions, which part of the notes they were found and whether they were corrected.
Results
Forty-four transposition errors were found in 32 sets on notes. The commonest error was drawing the eye on the wrong side of the page. The commonest place where errors were found was in the written outpatient notes. Nineteen of the errors had evidence of later correction. Three consent forms had the incorrect eye denoted and one patient was listed for surgery on the wrong side although this error was corrected before the operation.
Conclusion
As far as we are aware, this study is the first to look at how often, in standard clinical notes, left/right transposition occurs. Although a direct link cannot made between their occurrence and later wrong side surgery, intuitively it would be reasonable to think it could increase the likelihood if other defences were to fail. We make a number of recommendations that might reduce this confusion and therefore more serious consequences.