Lessons learned: wrong intraocular lens.
OBJECTIVE
To report cases involving the placement of the wrong intraocular lens (IOL) at the time of cataract surgery where human error occurred.


METHODS
Retrospective small case series, convenience sample.


METHODS
Seven surgical cases.


METHODS
Institutional review of errors committed and subsequent improvements to clinical protocols.


METHODS
Lessons learned and changes in procedures adapted.


RESULTS
The pathways to a wrong IOL are many but largely reflect some combination of poor surgical team communication, transcription error, lack of preoperative clarity in surgical planning or failure to match the patient, and IOL calculation sheet with 2 unique identifiers.


CONCLUSIONS
Safety in surgery involving IOLs is enhanced both by strict procedures, such as an IOL-specific "time-out," and the fostering of a surgical team culture in which all members are encouraged to voice questions and concerns.
Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA. oschein@jhmi.edu
Oliver D
OD
Schein
James T
JT
Banta
Teresa C
TC
Chen
Scott
S
Pritzker
Andrew P
AP
Schachat
D002387:Cataract Extraction; D020878:Device Removal; D006801:Humans; D019654:Lens Implantation, Intraocular; D007910:Lenses, Intraocular; D019300:Medical Errors / Q000517:prevention & control* / Q000706:statistics & numerical data; D055095:Optics and Photonics; D012086:Reoperation; D012189:Retrospective Studies; D012308:Risk Management; D014792:Visual Acuity / Q000502:physiology