{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,1,22]],"date-time":"2026-01-22T16:26:39Z","timestamp":1769099199646,"version":"3.49.0"},"reference-count":26,"publisher":"Georg Thieme Verlag KG","issue":"01","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Klin Monbl Augenheilkd"],"published-print":{"date-parts":[[2026,1]]},"abstract":"<jats:title>Zusammenfassung<\/jats:title>\n                  <jats:p>Hintergrund Beschrieben wird das Risikomanagement an einer Universit\u00e4ts-Augenklinik nach 2 Ausbr\u00fcchen von nosokomialen Endophthalmitis-F\u00e4llen nach Pars-plana-Vitrektomie.<\/jats:p>\n                  <jats:p>Methoden Bei 2 Serien postoperativer Endophthalmitis-F\u00e4lle nach hauseigener Vitrektomie wurden bez\u00fcglich Patientensicherheit die grundlegenden Arbeitsabl\u00e4ufe in der direkten Patientenversorgung evaluiert und hygienisch mikrobiologische Umgebungsuntersuchungen an relevanten Materialien und Oberfl\u00e4chen durchgef\u00fchrt sowie insbesondere die direkten OP-Utensilien hinsichtlich m\u00f6glicher Keimbesiedelung untersucht.<\/jats:p>\n                  <jats:p>Ergebnisse Bei 2 von 7 Endophthalmitis-F\u00e4llen konnten Erreger (Staphylococcus aureus) nachgewiesen werden. Die S.-aureus-St\u00e4mme wiesen keine Klonalit\u00e4t auf. Bei den Eingriffen handelte es sich um 23-G- und 25-G-Vitektomien bei Ablatio (3\u00d7 rhegmatogen, 1\u00d7 PVR), subretinaler Makulablutung (1\u00d7) und Glask\u00f6rperblutung bei Proliferativer Retinopathie (2\u00d7). Die OP-Dauern lagen zwischen 20\u2009min und 65\u2009min, die Zeitspanne zwischen Erst-OP und OP der Endophthalmitis betrug zwischen 2 und 5\u2009Tagen (durchschnittlich 3,6\u2009Tage). Es wurde bei Erst-Operation 1\u00d7 eine Silikon\u00f6lf\u00fcllung instilliert und ansonsten das Auge mit Gas (4\u00d7) oder Luft (2\u00d7) tamponiert. Das OP-Team war heterogen, es waren n\u2009=\u20095 Operateure beteiligt und die initialen Operationen fanden in n\u2009=\u20094 unterschiedlichen OP-S\u00e4len statt. Die Operationen wurden allesamt in Vollnarkose durchgef\u00fchrt (6\u00d7 Larynxmaske, 1\u00d7 endotracheale Intubation). Es fand sich keine definitive Infektionsquelle. Die Interventionen bez\u00fcglich der\n          Patientensicherheit zielten daher auf die St\u00e4rkung der Compliance vorhandener Infektionspr\u00e4ventions-Ma\u00dfnahmen und der Anpassung der Arbeitsabl\u00e4ufe ab. In der Akutphase wurde entgegen dem sonst \u00fcblichen Prozedere intraoperativ Antibiose in die Vorderkammer nach Vitrektomie instilliert. Andere Arten von intraokularen Operationen waren nicht betroffen.<\/jats:p>\n                  <jats:p>Schlussfolgerung Die H\u00e4ufung von hauseigenen Endophthalmitis-F\u00e4llen ist in einer Augenklinik ein katastrophales Ereignis und es bedarf eines stringenten Risikomanagements zur Ursachenfindung. Dabei ist Offenheit und Transparenz ein wesentlicher Faktor f\u00fcr eine ad\u00e4quate Aufarbeitung. Diese Arbeit zeigt auf, wie die einzelnen Schritte ausgesehen haben und wie mit den Ergebnissen umgegangen werden kann. Die Problematik, keine eindeutige Punktquelle f\u00fcr die Infektionen gefunden zu haben, wird diskutiert.<\/jats:p>","DOI":"10.1055\/a-2663-5981","type":"journal-article","created":{"date-parts":[[2025,9,1]],"date-time":"2025-09-01T23:04:24Z","timestamp":1756767864000},"page":"13-22","source":"Crossref","is-referenced-by-count":0,"title":["Patient Safety and Risk Management in an Accumulation of Postoperative Endophthalmitis Cases after Vitrectomy in a University Eye Clinic"],"prefix":"10.1055","volume":"243","author":[{"given":"Carsten","family":"Framme","sequence":"additional","affiliation":[{"name":"Klinik f\u00fcr Augenheilkunde, Medizinische Hochschule Hannover, Deutschland"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Helmut G.","family":"Sachs","sequence":"additional","affiliation":[{"name":"Klinik f\u00fcr Augenheilkunde, Medizinische Universit\u00e4t Lausitz \u2013 Carl Thiem, Cottbus, 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