Safer Surgical Site Marking for patients undergoing Eye Surgery by using Human Factors Engineering Approach
Care Process & Redesign
Yishun Health One Improvement Festival
National Healthcare Group
8 April 2025
A multi-disciplinary project that aims to identify and address the human factors ergonomics that contribute to wrong. The Eye label is a simple and effective tool in improving patient safety during surgery site identification.
Year Submitted: 2025
Published Date: 08 April 2025
Tags: Quality Improvement, Workflow Redesign, Care Process ＆ Redesign, Value Based Care, Safe Care, Functional Outcome
About this Content
Aims
A multi-disciplinary project that aims to identify and address the human factors ergonomics that contribute to wrong surgical site identification and reduce wrong site eye surgery to zero incidences, enhancing patient safety during the process of surgery site identification.
Background
DSC had encountered 2 wrong site eye surgeries. The team mapped out a swim lane diagram on Eye patient’s perioperative care process and studied the work ergonomics of the stakeholders involved in surgery site marking.
Methods
The SEIPS Human Factors framework was used to understand the human factors relationship within the perioperative environment. A [RIGHT LEFT] label was designed to ameliorate cognitive and auditory distractions and interruptions during surgical site marking.
Results
To date, there is zero wrong site surgery. The Eye label has identified and addressed the human factors during the surgical site marking process.
Conclusion
The Eye label is a simple and effective tool in improving patient safety during surgery site identification. It has reached its one-year milestone of zero error since the start of the project and is now the standard of care.
Lessons Learnt
Swim lane and Ergonomic studies identified areas with high levels of human error preconditions such as poor communication, distraction, stress, complacency, lack of teamwork, and lack of awareness.
Additional Information
The Eye label is mandated for use in all Eye surgery patients since October 2022. The project is sustained with 6-sigma methodology. Special acknowledgement to Prof Tan KY for his contribution on Safer Surgical Site Marking practices.
Keywords
Surgery, Patient Safety, Human Factors, Ergonomics, Eye Surgery
Innovators' Details
Innovators' Details
Healthcare Cluster(s) | National Healthcare Group |
Organization(s) Involved | Khoo Teck Puat Hospital |
Platform(s) | Yishun Health One Improvement Festival |
Healthcare Professional Group(s) | Nursing, Medical |
Applicable Specialty or Discipline | Ophthalmology, Surgery |
Project Lead(s) | Lai Foon Wan |
Project Member(s) | Benjamin Chang |
Connect with this contributor!
KTPH & YCH Innovation & Improvement (I&I) Office - i-i@ktph.com.sg
Project Attachment
763_KTPH_OIF 2025_Safer Surgical Site Marking for patients underg.pdf