Surgical confusions have been rarely studied, especially in ophthalmology. The author hypothesized that such confusions occur rarely but are unacceptable in the public, legal, and regulatory arenas; often occur in circumstances presenting predictable risk; more often involve wrong lens implant than wrong eye, procedure, or patient; and can be prevented by following the Universal Protocol.

A retrospective series of 106 cases occurring between 1982 and 2005 included 42 closed files from the Ophthalmic Mutual Insurance Company and 64 cases reported to the New York State Health Department. Records were grouped by procedure planned and analyzed to answer these questions: How did the error occur? By whom and when was the error recognized? Who was responsible? Was the patient informed? What was done to the patient? What was the outcome? What liability payments were made? What policy changes or sanctions resulted? Was the error preventable by following the Universal Protocol?

The most common confusion was wrong lens implant, accounting for 67 (63%) of the 106 cases. Wrong eye surgery occurred in 15 cases, wrong eye blocks in 14, wrong patient/procedure in 8, and wrong corneal transplant in 2. In 16 cases, the Universal Protocol would have been unlikely to prevent the confusion.

Surgical confusions occur infrequently and usually cause little or no permanent injury, but they may be devastating to the patient, the physician, and the profession. Measures to prevent such confusions, including the Universal Protocol and related checklists, deserve the acceptance, support, and active participation of ophthalmologists.