A retrospective case series looking at sources of errors in patients undergoing laser refractive surgery. Twenty-two cases of error were identified in 18 patients; 15 were unilateral, three bilateral and two errors occurred in the same eye (on attempting correction of first error). Sources of error included cylinder conversion (11 eyes), data entry (seven eyes) and patient identification (four eyes). Patients that were not candidates for further surgery and those with data entry errors had the worst outcome. The paper discusses similar reports in the literature and although it makes interesting reading, the sample is small and biased (most cases reported here were operated on elsewhere). The authors’ own estimate is an incidence of 280 to 400 cases of error per year, suggesting that most cases are not reported in the literature.

Sources of medical error in refractive surgery.
Moshirfar M, Simpson RG, Dave SB, et al.
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Amit Patel

Heart of England NHS Foundation Trust, Birmingham, UK

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