Abstract
Purpose
To consider wrong intraocular lens (IOL) implant events in cataract surgical care reported through a national incident reporting database. To propose potential solutions for such events where possible.
Methods
Thematic retrospective review of wrong IOL implantation incidents, as reported through clinical incident reporting methods in NHS care in England and Wales from 2003 to 2010, ascertained from database mining at the National Patient Safety Agency.
Results
In total, 164 patient safety incident (PSI) reports of wrong IOL implantation were located from the study period and considered. There were 47 reports where further surgical intervention was required. All, but one of these required IOL exchange surgery. A total of 62 reports did not provide any causal reason for the wrong IOL implantation and thus provide little if any potential learning. Inaccurate biometry (n=29), wrong IOL selection (n=21), transcription errors (n=10) and handwriting misinterpretations (n=7) were causal reasons reported and are thus potential areas for ophthalmic teams to review and improve practice.
Conclusion
Although infrequent, biometry/IOL implant errors or wrong implants do occasionally occur during cataract care and are thus a threat to quality. There is room for improvement in incident reporting in NHS cataract care as root causation of error was usually lacking in the PSI reports. Nevertheless, lessons for improvement of care from a national incident reporting database for a frequently undertaken surgical procedure were found. Suggestions are proposed for improving quality by reducing wrong IOL problems in cataract care based on analysis of such reports.
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Acknowledgements
We thank Michael Surkitt-Parr at the NPSA for undertaking database searches. We thank Fran Watts, Patient Safety Lead, for surgery of the NPSA and Richard Smith, recent Chairman of Professional Standards Committee of the Royal College of Ophthalmologists, for comments on early drafts of the manuscript.
Contributors: SPK and AJ are responsible for drafting this manuscript. SPK is the guarantor of this article.
Ethical approval: A data-sharing undertaking between SPK and the National Patient Safety Agency was undertaken in line with data protection procedures at the NPSA. No identifiable patient data were viewed in data analysis.
Provenance and peer review: Not commissioned; externally peer reviewed.
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The authors declare no conflict of interest.
Additional information
Presented in part at 2009 Annual Scientific Congress of the Royal College of Ophthalmologists. Following a Department of Health review in July 2010, the National Patient Safety Agency will be abolished and some of its functions transferred to a Patient Safety subcommittee of the new NHS Commissioning Board. Reports of incidents are, however, still encouraged at www.npsa.nhs.uk
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Kelly, S., Jalil, A. Wrong intraocular lens implant; learning from reported patient safety incidents. Eye 25, 730–734 (2011). https://doi.org/10.1038/eye.2011.22
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DOI: https://doi.org/10.1038/eye.2011.22
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