Incidence and Impact of Reported Infectious Endophthalmitis Events Following Cataract Surgery in Pennsylvania Ambulatory Surgery Centers


  • Lynette Hathaway Patient Safety Authority
  • Shawn Kepner Patient Safety Authority
  • Rebecca Jones Patient Safety Authority



infectious endophthalmitis, eye infection, cataract surgery, postoperative endophthalmitis, healthcare-associated infection


Infectious endophthalmitis is a severe eye infection that can occur following cataract surgery. In this study, we sought to explore post-cataract infectious endophthalmitis events reported by ambulatory sur-gery centers (ASCs) in Pennsylvania. We queried the Pennsylvania Patient Safety Reporting System (PA-PSRS) database for
post-cataract endophthalmitis events that occurred be-tween 2009 and 2018. In the 10 cal-endar years analyzed, we identified 174 reports of post-cata-ract endophthalmitis, with rates per 1000 cataract procedures anging from 0.05 in 2009 to 0.19 in 2018. The vast majority of these events were classified as serious (93%; n = 162 of 174), reflecting harm to patients, with one resulting in enucleation (the need to remove the affected eye). Healthcare staff and all involved stakeholders should act now by identifying sources of potential perioperative contamination, adhering to evidence-based infection prevention practices, and prioritizing areas of opportunity for improvement. 

Author Biographies

Lynette Hathaway, Patient Safety Authority

Lynette Hathaway is an infection prevention analyst for the Patient Safety Authority, where she assists with the improvement of patient safety by initiating, developing, implementing, and monitoring new and existing infection prevention initiatives throughout Pennsylvania. Her diverse nursing experience in-cludes cardiovascular and medical-surgical nursing, gastroenterology, utilization review, long-term care, nursing education, and infection prevention and con-trol. Prior to joining the PSA, Hathaway was manag-er of Infection Prevention and Control at a 156-bed acute care facility. She is board-certified in infection control and epidemiology, and an active member of the Three Rivers Chapter of the Association for Pro-fessionals in Infection Control and Epidemiology.

Shawn Kepner, Patient Safety Authority

Shawn Kepner is a data analyst for the Patient Safety Authority, providing actionable insights using data science techniques, working with staff to focus resources and research for maximum benefit to patient safety, and helping assess the quality and validity of statistical methodologies for research and publications. Before joining the PSA, Kepner was a contractor with the Pennsylvania Department of Health, where he served as the data manager for a new community health initiative. His prior positions include decision support consultant and manager of informatics for Novitas Solutions, bureau director for program support with the Pennsylvania Department of Public Welfare (DPW), and program manager with Xerox Corporation. He also has been an adjunct mathematics instructor at Harrisburg Area Community College and a presenter on statistics to the DPW’s Leadership Development Institute.

Rebecca Jones, Patient Safety Authority

Rebecca Jones ( is director of Data Science and Research at the Patient Safety Authority, where she also founded and serves as director of the Center of Excellence for Improving Diagnosis. Her previous roles at the PSA include director of Innovation and Strategic Partnerships, and regional patient safety liaison. Before joining the PSA, Jones served in various roles leading patient safety efforts and proactively managing risk in healthcare organizations. She currently is chair of the Practice Committee of the Society to Improve Diagnosis in Medicine and serves on the Advisory Committee of the Coalition to Improve Diagnosis.


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How to Cite

Hathaway, L., Kepner, S., & Jones, R. . (2019). Incidence and Impact of Reported Infectious Endophthalmitis Events Following Cataract Surgery in Pennsylvania Ambulatory Surgery Centers. Patient Safety, 1(2), 24–35.



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