Lessons from Ophthalmology in Preventing Wrong-Site Errors in Paired-Organ Surgery
Round 1
Reviewer 1 Report
Comments and Suggestions for AuthorsThank you for the opportunity to review this well thought out and well written article.
Excellent work.
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3.24 update
Further comments on Lessons from Ophthalmology in Preventing Wrong-Site Errors in Paired-Organ Surgery
This paper is relevant to all specialties that deal with invasive procedures that involve paired-organs. It is also timely because despite recent advances in prevention, errors involving the wrong side with respect to the diagnosis and/or surgery persist. In addition, these ‘never should happen’ events continue across many specialties. Hence the current relevance of this article.
This article looks specifically at Ophthalmology and breaks down the causes for these errors. The mistakes vary depending upon the type of surgery performed on the eye in question. However, the main causes of surgical errors involve problems with the surgical planning and communication among the team members. And this problem exists across all specialties.
This article has offered a strong and extensive review of the literature on medical errors. It has collated and updated the information in this field.
This article offers strategies to prevent these ‘never’ events including but not limited to the use of artificial intelligence. In addition, it suggests that augmented reality and virtual reality are areas under current investigation.
The conclusions are consistent with the subject matter of the article and offer appropriate directions in the prevention of ‘never’ events across the specialties that deal with paired-organ surgery.
Author Response
We deeply thank the reviewer for the comments. We hope this article would be interesting for the readers, too!
Reviewer 2 Report
Comments and Suggestions for AuthorsThe present manuscript is of high clinical relevance because of the fact that surgical errors involving paired organs may have severe consequences, particularly in procedures where laterality is a critical factor.
Consequently, risk management and patient safety protocols requiring continuous improvements in preventive strategies are mandatory.
Standardized procedures to prevent these principally preventable events have subsequently been adapted to ophthalmic surgery by specialized scientific societies.
Additionally, multidisciplinary interventions, including AI-assisted verification systems, human factors analyses, and enhanced surgical checklists, continued to strengthen error prevention in general. This present review manuscript examined the implementation and development of these strategies in ophthalmic surgery, evaluating effectiveness and identifying persistent challenges in general surgical safety.
The introduction showed a consistent overview about the problem of laterality errors. Particularly, figure 1 showed the schematic representation of paired organs in a good and impressive way.
It was well explained to the readers why ophthalmology served as a very valuable model for understanding and preventing wrong-site errors in paired-organ surgery.
The literature is covering all important aspects and the references are consistent.
Figure 2 should be improved by the authors. The schematic workflow is not easy to be understood. A distinction between the different failure causes should be added, as well as their different impact on surgical safety. Distractions, stress, and fatigue can cause deviations from standard protocols. It would be important to show how the combination of severals errors may increase / multify the negative impact! It is selodom only an isolated error, mostly a combination leading to catastrophe. In summery, a culture of mutual vigilance and well-structured safety measures is critical. This should be presented better in this figure.
The methods section is fine. Also the list of the main surgical errors in ophthalmology is well written and presented.
The conclusion is quite short and I would recommend to discuss the results more detailed.
In summery, a very interesting and important manuscript.
Author Response
We thank the reviewer for the comments and the suggestion for improvement. We provided an improved Figure 2 as requested and enriched the discussion.
Reviewer 3 Report
Comments and Suggestions for AuthorsThe manuscript fails to cite the pivotal study titled “Deep learning-based smart speaker to confirm surgical sites for cataract surgeries: A pilot study” (PLoS ONE, 2020). This study is highly relevant, as it represents an early real-world implementation of an AI-powered voice assistant in verifying surgical laterality and procedure, directly aligning with the manuscript’s emphasis on AI-assisted verification strategies. Its omission is a significant oversight that undermines the completeness of the technological section.
The authors should include a section—either in the introduction or discussion—that outlines the global burden of surgical errors attributed to human factors (e.g., fatigue, miscommunication, cognitive bias). References such as the World Health Organization’s Patient Safety reports and The Lancet Commission on Global Surgery may help frame the ophthalmic examples within this broader public health challenge. This addition would strengthen the manuscript's relevance and provide a global health context for the urgency of adopting safety protocols and AI-based solutions.
Insufficient Exploration of Future Technologies, Including Interactive AI like GPT
The manuscript briefly mentions machine learning and AR/VR applications but omits discussion of emerging interactive AI technologies, such as multimodal large language models (LLMs) like GPT-4, which are increasingly being integrated into surgical planning, checklist automation, and real-time intraoperative support. These models offer context-aware conversation, natural language understanding, and even voice-based verification that could serve as digital surgical assistants or augment team communication to reduce human error.
Although the authors mention a search strategy, the review lacks the transparency and rigor of a systematic review. There is no PRISMA diagram, table of included studies, or risk of bias assessment. The structure is largely narrative, leading to selective citation and missed important works.
While the “Universal Protocol” is mentioned, the manuscript fails to emphasize the critical role of the time-out procedure as the final and most enforceable barrier to prevent wrong-site surgery.
Author Response
The manuscript fails to cite the pivotal study titled “Deep learning-based smart speaker to confirm surgical sites for cataract surgeries: A pilot study” (PLoS ONE, 2020). This study is highly relevant, as it represents an early real-world implementation of an AI-powered voice assistant in verifying surgical laterality and procedure, directly aligning with the manuscript’s emphasis on AI-assisted verification strategies. Its omission is a significant oversight that undermines the completeness of the technological section.
A: Thank you for the indication we added the suggested article in the appropriate section.
The authors should include a section—either in the introduction or discussion—that outlines the global burden of surgical errors attributed to human factors (e.g., fatigue, miscommunication, cognitive bias). References such as the World Health Organization’s Patient Safety reports and The Lancet Commission on Global Surgery may help frame the ophthalmic examples within this broader public health challenge. This addition would strengthen the manuscript's relevance and provide a global health context for the urgency of adopting safety protocols and AI-based solutions.
A: Thank you for the suggestion, we provided, in the introduction a detailed description of the global burden of the surgical errors.
Insufficient Exploration of Future Technologies, Including Interactive AI like GPT
The manuscript briefly mentions machine learning and AR/VR applications but omits discussion of emerging interactive AI technologies, such as multimodal large language models (LLMs) like GPT-4, which are increasingly being integrated into surgical planning, checklist automation, and real-time intraoperative support. These models offer context-aware conversation, natural language understanding, and even voice-based verification that could serve as digital surgical assistants or augment team communication to reduce human error.
A: Thank you for the indication and suggestion. We performed a thorough research on the topic as requested and updated the relative paragraph in the discussion.
Although the authors mention a search strategy, the review lacks the transparency and rigor of a systematic review. There is no PRISMA diagram, table of included studies, or risk of bias assessment. The structure is largely narrative, leading to selective citation and missed important works.
A: The submitted work is not a systematic review but a narrative one, therefore, it doesn't follow the PRISMA guidelines, and we didn't include a PRISMA diagram. However, for completeness and reproducibility of our research, we included a method section for completeness.
While the “Universal Protocol” is mentioned, the manuscript fails to emphasize the critical role of the time-out procedure as the final and most enforceable barrier to prevent wrong-site surgery.
A: We thank the reviewer for this important point. We have now added a sentence to highlight the time-out procedure as the final and most enforceable barrier within the Universal Protocol to prevent wrong-site surgery.
Round 2
Reviewer 3 Report
Comments and Suggestions for AuthorsI think table 2 also needs references.
Author Response
Thank you! We've added references to Table 2 as requested.