O uso de checklists em cirurgias oftalmológicas e a prevenção de eventos adversos: revisão integrativa
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Jun 3, 2025
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Resumo
Objetivo: Avaliar o impacto da implementação de checklists de segurança cirúrgica na redução de eventos adversos e na melhoria da segurança do paciente em cirurgias oftalmológicas. Métodos: Revisão integrativa realizada a partir de estudos nas bases MEDLINE, EMBASE, Cochrane Library, Web of Science, Scopus e Google Scholar. Foram incluídos ensaios clínicos randomizados, estudos observacionais e pesquisas qualitativas. A análise seguiu a síntese temática de Bardin e os estudos foram avaliados quanto ao risco de viés. Resultados: Foram analisados 17 estudos que utilizaram diferentes checklists. O Checklist de Segurança Cirúrgica da OMS foi o mais aplicado, reduzindo erros de identificação do paciente, marcação cirúrgica incorreta e implantação errada de lentes intraoculares. Outros checklists, como o Universal Protocol e o ClassIntra, também demonstraram impacto positivo. As principais barreiras à implementação incluem sobrecarga de trabalho, resistência dos profissionais e falta de padronização institucional. Considerações finais: A adoção de checklists cirúrgicos em oftalmologia reduz eventos adversos e melhora a comunicação entre equipes, mas enfrenta desafios de adesão. Estudos futuros devem validar versões adaptadas e explorar estratégias para ampliar sua implementação no contexto clínico.
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Como Citar
SilvaM. P. da, MartinsG., SilvaE. A. S. da, CâmaraA. M. M., & BarbosaM. A. (2025). O uso de checklists em cirurgias oftalmológicas e a prevenção de eventos adversos: revisão integrativa. Revista Eletrônica Acervo Saúde, 25(6), e20386. https://doi.org/10.25248/reas.e20386.2025
Seção
Revisão Bibliográfica
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Referências
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14. HUSSNAIN SA, et al. Use of the American Academy of Ophthalmology Surgical Checklist and Implant Timeouts: An Online Survey of Connecticut Ophthalmologists. J Clin Exp Ophthalmol, 2015; 6(496):2-11.
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16. KESSELS-HABRAKEN M, et al. Defining near misses: towards a sharpened definition based on empirical data about error handling processes. Soc Sci Med, 2010; 70(9):1301-1308.
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24. ROBERT MC, et al. Avoidance of serious medical errors in refractive surgery using a custom preoperative checklist. J. Cataract Refractive Surg., 2015; 41(10):2171-2178.
25. STEEPLES LR, et al. Wrong intraocular lens events-what lessons have we learned? A review of incidents reported to the National Reporting and Learning System: 2010-2014 versus 2003-2010. Eye (London, England), 2016; 30(8):1049-1055.
26. STOLK-VOS AC, et al. A Digital Patient-Led Hospital Checklist for Enhancing Safety in Cataract Surgery: Qualitative Study. JMIR perioperative medicine, 2018; 1(2):e3.
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28. TORU HK, et al. Compliance With the World Health Organization Surgical Safety Checklist at a Tertiary Care Hospital: A Closed Loop Audit Study. Cureus, 2023; 15(5):e39808.
29. TURLEY N, et al. International Perspectives on Modifications to the Surgical Safety Checklist. JAMA Network Open, 2023; 6(6):e2317183-e2317183.
30. WEINGESSEL B, et al. Clinical risk management – a 3-year experience of team timeout in 18 081 ophthalmic patients. Acta Ophthalmologica, 2017; 95(2):e89-e94.
31. WHITTEMORE R, KNAFL K. The integrative review: updated methodology. J. Adv. Nurs., 2005; 52(5):546-553.
32. WINKLMAIR N, et al. Sustainable practices in ophthalmology—steps towards environmental stewardship in healthcare. Wiener Medizinische Wochenschrift, 2024; 1(1):125-129.
33. WORLD HEALTH ORGANIZATION. Implementation manual surgical safety checklist (first edition). Geneva: World Health Organization, 2008. Disponível em: Acesso em: 29 dez 2024.
34. ZAMIR E, et al. Intraocular lens confusions: a preventable "never event" - The Royal Victorian Eye and Ear Hospital protocol. Survey of ophthalmology, 2012; 57(5):430-447.
35. ZASLOW J, et al. The problem with ‘never events’. BMJ, 2024; 33(9):613-617.
2. ALSADOUN L, et al. Evaluating the Impact of the World Health Organization's Surgical Safety Checklist on Clinical Outcomes and Implementation Strategies: A Systematic Review. Cureus, 2024; 16(9):e69875.
3. AMORIM RIBEIRO IC, SILVA CUNHA KC. Evaluación del clima de seguridad del paciente en un hospital quirúrgico oftálmico. Enfermería Global, 2018; 17(1):316-364.
4. BAIRD DR, et al. Post-operative endophthalmitis: The application of hazard analysis critical control points (HACCP) to an infection control problem. Journal of Hospital Infection, 2001; 49(1):14-22.
5. BARDIN L. Análise de conteúdo. 3rd ed. São Paulo, Brasil: Edições, 2016. 277 p.
6. BOESE EA, et al. Implementation of a Standardized Patient Safety Checklist in Ophthalmic Surgery. Journal of Academic Ophthalmology, 2018; 10(1):e172-e178.
7. BOSSONG O, et al. Prospective Cohort Study of In-Hospital Patients Undergoing Ophthalmic Surgery for the Validation of ClassIntra: Classification of Intraoperative Adverse Events. Klin Monbl Augenheilkd, 2021; 238(4):510-520.
8. CAVALLINI GM, et al. Clinical risk management in eye outpatient surgery: A new surgical safety checklist for cataract surgery and intravitreal anti-VEGF injection. Graefe's Archive for Clinical and Experimental Ophthalmology, 2013; 251(3):889-894.
9. DONACHIE PHJ, et al. The Royal College of Ophthalmologists’ National Ophthalmology Database study of cataract surgery: Report 9, Risk factors for posterior capsule opacification. Eye, 2023; 37(8):1633-1639.
10. ENDALAMAW A, et al. A scoping review of continuous quality improvement in healthcare system: conceptualization, models and tools, barriers and facilitators, and impact. BMC Health Services Research, 2024; 24(1):487-500.
11. FALCÃO AS, et al. Adherence to the completion of the safe surgery checklist in ophthalmic surgeries. Rev. SOBECC (Online), 2024; 1(1):E2429985-E2429985.
12. GARG R. To study the existing system of surgical safety for cataract surgery at tertiary care ophthalmic centre to implement who surgical safety checklist. Antimicrob. Resist. Infect. Control, 2023; 12(1):0-19.
13. GOEKCIMEN K, et al. Addressing Patient Safety Hazards Using Critical Incident Reporting in Hospitals: A Systematic Review. Journal of Patient Safety, 2023; 19(1):1549-8417.
14. HUSSNAIN SA, et al. Use of the American Academy of Ophthalmology Surgical Checklist and Implant Timeouts: An Online Survey of Connecticut Ophthalmologists. J Clin Exp Ophthalmol, 2015; 6(496):2-11.
15. KELLY SP, et al. Surgical checklist for cataract surgery: Progress with the initiative by the Royal College of Ophthalmologists to improve patient safety. Eye (Basingstoke), 2013; 27(7):878-882.
16. KESSELS-HABRAKEN M, et al. Defining near misses: towards a sharpened definition based on empirical data about error handling processes. Soc Sci Med, 2010; 70(9):1301-1308.
17. KRISHNAN NR, KASTHURI AS. Iatrogenic Disorders. Med J Armed Forces India, 2005; 61(1):2-6.
18. LORKOWSKI J, et al. Causes and Effects of Introducing Surgery Safety Checklist: A Review. In: Best Practice in Health Care. POKORSKI M. Cham: Springer International Publishing, 2021: 53-62 p.
19. MACHIN H. Introducing the WHO's Safe Surgery Saves Lives initiative to ophthalmic nurses involved in ORBIS' training programmes. International Journal of Ophthalmic Practice, 2011; 2(4):159-165.
20. MALOLEY L, et al. Wrong-site surgery in pediatric ophthalmology. Journal of Pediatric Ophthalmology and Strabismus, 2018; 55(3):152-158.
21. PAGE MJ, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ, 2021; 372(71):1-14.
22. PARIKH R, et al. Surgical Confusions in Ophthalmology: Description, Analysis, and Prevention of Errors from 2006 through 2017. Ophthalmology, 2020; 127(3):296-302.
23. PATERSON C, et al. Barriers and facilitators associated with the implementation of surgical safety checklists: A qualitative systematic review. Journal of Advanced Nursing, 2024; 80(2):465-483.
24. ROBERT MC, et al. Avoidance of serious medical errors in refractive surgery using a custom preoperative checklist. J. Cataract Refractive Surg., 2015; 41(10):2171-2178.
25. STEEPLES LR, et al. Wrong intraocular lens events-what lessons have we learned? A review of incidents reported to the National Reporting and Learning System: 2010-2014 versus 2003-2010. Eye (London, England), 2016; 30(8):1049-1055.
26. STOLK-VOS AC, et al. A Digital Patient-Led Hospital Checklist for Enhancing Safety in Cataract Surgery: Qualitative Study. JMIR perioperative medicine, 2018; 1(2):e3.
27. TORONTO CE. Overview of the Integrative Review. In: TORONTO CE; REMINGTON R (Org.). A Step-by-Step Guide to Conducting an Integrative Review. Cham: Springer International Publishing, 2020. p.1-9. ISBN 978-3-030-37504-1.
28. TORU HK, et al. Compliance With the World Health Organization Surgical Safety Checklist at a Tertiary Care Hospital: A Closed Loop Audit Study. Cureus, 2023; 15(5):e39808.
29. TURLEY N, et al. International Perspectives on Modifications to the Surgical Safety Checklist. JAMA Network Open, 2023; 6(6):e2317183-e2317183.
30. WEINGESSEL B, et al. Clinical risk management – a 3-year experience of team timeout in 18 081 ophthalmic patients. Acta Ophthalmologica, 2017; 95(2):e89-e94.
31. WHITTEMORE R, KNAFL K. The integrative review: updated methodology. J. Adv. Nurs., 2005; 52(5):546-553.
32. WINKLMAIR N, et al. Sustainable practices in ophthalmology—steps towards environmental stewardship in healthcare. Wiener Medizinische Wochenschrift, 2024; 1(1):125-129.
33. WORLD HEALTH ORGANIZATION. Implementation manual surgical safety checklist (first edition). Geneva: World Health Organization, 2008. Disponível em:
34. ZAMIR E, et al. Intraocular lens confusions: a preventable "never event" - The Royal Victorian Eye and Ear Hospital protocol. Survey of ophthalmology, 2012; 57(5):430-447.
35. ZASLOW J, et al. The problem with ‘never events’. BMJ, 2024; 33(9):613-617.