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HomemiprofessionEvolving Practise: More than Meets the Eye

Evolving Practise: More than Meets the Eye

After five years as an optometrist, practice owner Stephanie Lord has learnt that mistakes happen, learning is a constant, and change is not optional.

I completed my optometry degree in 2015 and had a short gig in corporate practice before moving to take up a job in Jervis Bay on the south coast of New South Wales. I started at Bayside Optical in 2016, on the day the practice changed hands. It was a steep learning curve. The practice was only partly digitised with a mish-mash of systems and procedures. Four years later, somewhere between the devastating south coast bushfires and COVID-19, my partner James and I bought the practice. Our timing could have been better.

With this journey came a resolve to constantly assess risks

Much of my practice refinement has come about through errors – many small, some larger than I would like to admit. Perfection doesn’t exist when working with human beings. We are expected to give certain answers that are based on biological measurements and mental calculations of risk derived from sketchy and incomplete patient histories. We work in complex environments with time constraints and distractions. The seminal report, To Err is Human highlighted this, recommending “to create an environment that encourages organisations to identify errors, evaluate root causes in order to improve future performance.”1 

When something doesn’t go to plan, stepping back and asking what factors contributed to that outcome is a powerful learning tool. We also need to build redundancy into our systems to capture things if they happen to slip through the cracks.

A case of mine comes to mind – a bandage contact lens for recalcitrant dry eye led to microbial keratitis resulting in a poor visual outcome with sight left in just one eye. For weeks I felt like a ‘second victim’. This term refers to the impact on a practitioner of an unanticipated error, describing it as akin to a grief process. We go through stages of chaos and accident response, intrusive reflections, restoring personal integrity, enduring the inquisition, obtaining emotional first aid and finally moving on.2 If you’ve been in practice long enough, you may have experienced it.

With this journey came a resolve to constantly assess risks, analyse root causes of issues, and seek continuous quality improvement; to ask questions like, “what could happen?”, “why did that happen?” and “how can we prevent that from happening again?” This is a frame of mind I have adopted and carry throughout the entire patient journey.

Consider these two hypothetical cases:

A 38-year-old woman arrives at her appointment with two young children in tow. She is -2.00D and has new floaters but declines dilation because her kids won’t sit still for that long. A few weeks later she returns with a retinal detachment.

A 57-year-old woman comes in for a routine eye examination. Notes from her last eye test four years ago read “return to clinic for optical coherence tomography and field test due to elevated intraocular pressure”. There is no record of this being done and, while she recalls being asked to return for an expensive scan, she says she never bothered because her vision was fine. You find pressures of 28mmHg and advanced glaucomatous damage.

These scenarios highlight common contributors to errors we encounter almost daily. Assumptions and biases, disruptions and distractions, time constraints, poor communication and ineffective systems can lead to adverse outcomes.

Factors contributing to non-compliance are known to include a patient’s beliefs of necessity and efficacy of treatment, and the consequences of disease.3 A review of records of 145,234 patients lost to follow-up over a five year period at Moorfields Eye Hospital in the UK identified 16 serious incidents. 14 of these resulted in total loss of vision to glaucoma.4

When I started at Bayside Optical, I noticed many patients failed to return for field tests. To overcome this, I renamed field test appointments ‘glaucoma screenings’ and encouraged patients to book in before they left the practice. I now walk them out and formally handover to our front of house team with a written note to prompt the appointment booking. I also set a back-up recall notice. Anecdotally, I’m finding far fewer patients lost to follow-up.

Excellent quality eye care is not just about clinical skills or having access to the latest technology. It is the effective culmination of many components that begin with making enough time, eliminating interruptions and distractions, and implementing systems that facilitate the delivery of high quality and timely care.

Stephanie Lord is the practice owner of Bayside Optical in Jervis Bay, New South Wales. 

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