Intraocular lens confusions: a preventable "never event" - The Royal Victorian Eye and Ear Hospital protocol.
Intraocular lens (IOL) confusions and errors are among the most common postoperative adverse events. Errors may occur at any stage from the decision to operate to the insertion of the IOL. The most common errors occur during IOL selection pre-operative preparation (anaesthesia given before recognition that the intended IOL is not available), or intraoperatively (wrong IOL implanted because of confusion in the operating room). We review the mechanisms of errors reported in the literature and describe the experience at The Royal Victorian Eye and Ear Hospital. We also describe the implementation of an error-detection protocol and provide qualitative data on its performance.
Centre for Eye Research Australia and The University of Melbourne Department of Ophthalmology, Melbourne, Victoria, Australia. ezamir@unimelb.edu.au
Ehud
E
Zamir
Katarina
K
Beresova-Creese
Linda
L
Miln
D002387:Cataract Extraction / Q000592:standards*; D002985:Clinical Protocols / Q000592:standards*; D019091:Critical Pathways / Q000592:standards*; D006782:Hospitals, Special / Q000592:standards; D006801:Humans; D019654:Lens Implantation, Intraocular / Q000592:standards*; D007910:Lenses, Intraocular; D019300:Medical Errors / Q000517:prevention & control*; D009885:Ophthalmology / Q000592:standards; D017410:Practice Guidelines as Topic; D014739:Victoria