Introduction:

cataract surgery is among the safest procedures in medicine but it involves the actions of several health care professionals prone to occasional failures that can result in serious harm to patients. Patient safety is a serious global public health issue.

Objective:

to analyze incidents and adverse events related to cataract surgery in Holguín´s Ophthalmological Center.

Method:

a retrospective longitudinal cohort study with qualitative component was conducted. 2 192 cataract surgeries performed in 2018 were analyzed, following London Protocol. After selection of the research team, data were gathered and organized. Incidents and adverse events were appropriately identified. Unsafe actions and contributing factors were obtained by consensus after a qualitative analysis. Strategies for preventing them were recommended.

Results:

among the 2 192 cataract surgeries performed, 36 incidents and 69 adverse events were identified. The most frequent incidents were problems related to medical equipment (30.5%), scarce preoperative pupil dilation (25%) and delayed surgical time (16.6%). The most common adverse events were: severe trans-operative complications (33.3%) and surgical re-interventions (33.3%), most of them preventable, or probably preventable. Unsafe actions were mainly related to pre-operative and their contributing factors were multi-factorial.

Conclusions:

incidents and adverse events related to cataract surgery at Holguín´s Ophthalmological Center were under-reported. Contributing factors to unsafe actions involved the whole team and were preventable.

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