title: A review of safety incidents in England and Wales for vascular endothelial growth factor inhibitor medications.
abstract: OBJECTIVE
  To learn from patient safety incidents (PSIs) following recent introduction of vascular endothelial growth factor inhibitor medications (anti-VEGF) in ophthalmic care, as reported via a national incident reporting database.
  
  
  METHODS
  Thematic retrospective review of anti-VEGF medications PSIs as reported via 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 (NPSA).
  
  
  RESULTS
  In all, 166 relevant anti-VEGF incidents were reported. Reports have increased year on year from 2006. Incident severity as reported: 10 were reported as 'severe harm' and 23 as 'moderate harm'. The remainder were 'low' or 'no harm' events. The incident themes and/or causes found and by order of severity included: intra-ocular inflammation/endophthalmitis (n=16); treatment or follow-up delays (n=45); wrong medication (n=26); wrong eye/patient injection (n=17); missing records (n=12). Other problems included medication availability and refrigeration failures. We reflect on potential solutions for addressing the matters found. Systemic safety matters, stroke, subdural hemorrhage, and myocardial infarction (total n=3) followed anti-VEGF treatments.
  
  
  CONCLUSIONS
  Although infrequent, anti-VEGF medication PSIs or errors do occur and are thus a threat to quality. This review also provides supporting evidence to existing concerns and challenges surrounding age-related macular degeneration service pressures and provision. Lessons for improvement of care from a national incident reporting database for a frequently undertaken and recently introduced ophthalmic procedure were found. Suggestions are proposed for improving quality by reducing such problems based on analysis of such reports. Endophthalmitis reports following intra-vitreal injections suggest rigorous infection control measures are required.
authors.affiliation: Royal Bolton Hospital NHS Foundation Trust, Bolton, Lancashire, UK.
authors.forename: S P
authors.initials: SP
authors.lastname: Kelly
authors.forename: A
authors.initials: A
authors.lastname: Barua
mesh_terms: D000911:Antibodies, Monoclonal / Q000009:adverse effects*; D009877:Endophthalmitis / Q000139:chemically induced; D004739:England; D006801:Humans; D058449:Intravitreal Injections / Q000009:adverse effects; D008268:Macular Degeneration / Q000188:drug therapy*; D019300:Medical Errors / Q000706:statistics & numerical data*; D008508:Medication Errors / Q000706:statistics & numerical data; D012189:Retrospective Studies; D042442:Vascular Endothelial Growth Factors / Q000037:antagonists & inhibitors*; D014852:Wales
chemical_list: D000911:Antibodies, Monoclonal; D042442:Vascular Endothelial Growth Factors