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Communication failures are a major cause of sentinel perioperative adverse events and complications. We implemented a care improvement project to improve ophthalmic perioperative communication at Clements University Hospital (CUH). An expulsive choroidal hemorrhage (ECH) event occurred at CUH in 2018, prompting an investigation of the processes and procedures employed in ophthalmic surgery participants. It was determined to study this by an online survey of perioperative providers before and after intervention, with the intervention being a brief perioperative checklist during any patient handoff to facilitate communication between providers from May 2019 to August 2019. ECH is caused by a sudden decrease in intraocular pressure associated with surgical decompression of the globe 1; although rare, ECH can result in extremely poor visual outcomes. 1, 2

The Joint Commission has identified failed …