IOL Errors Persist Despite Checklists

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A review of National Health Service (NHS) data in the United King­dom shows that wrong intraocular lens (IOL) implantation still occurs, despite the introduction of surgical checklists designed to prevent this mistake.¹ Human factors are mostly to blame, ac­cording to the British researchers who studied patient safety incidents (PSIs) involving IOLs.

“In the U.K., cataract surgery carries a greater risk of inserting a wrong im­plant than any other procedure requir­ing an implant,” said lead author Laura R. Steeples, MBChB Hons, FRCOphth, consultant ophthalmic surgeon, at Manchester Royal Eye Hospital.

Although this retrospective review involved PSIs reported in England and Wales, Dr. Steeples said, “Wrong IOL implants are a global problem.” An analysis of errors at the Veterans Health Administration confirms a similar problem in the United States.²

A closer look at IOL errors. The au­thors considered 178 wrong IOL inci­dents reported between 2010 and 2014. They compared these incidents with previously analyzed occurrences from 2003 through 2010. They wanted to assess whether causation of errors had changed following significant patient safety initiatives and the implementation of surgical checklists in 2010.

At a minimum, the authors expected to see a reduction in mistakes involving matching data with the correct patient or eye. They also anticipated seeing fewer team communication errors. “We were surprised by how many mistakes [n = 26] involved incorrect transcription of the selected IOL to other sources and subsequent failure to refer to original source documents,” Dr. Steeples said.

Complex causation. Errors occurred at every stage, from preoperative (biometry or transcription error) to intraoperative (changes in planned procedure) to perioperative (handwrit­ing misinterpretations and wrong IOL brought into the operating room).

The NHS considers these incidents to be “never events,” defined by the U.K. National Patient Safety Agency as “serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented.” Yet they are difficult to eliminate. “The selection and implantation of the correct IOL is a complex process involving mul­tiple team members, with numerous potential sources of error,” Dr. Steeples said. “The current safety processes do not protect against mistakes cascad­ing through the pathway, resulting in wrong IOL implantation.”

Among other findings:

• Misfiling of the biometric data in the wrong patient notes was reported in far more incidents after 2010 (21/178) than in the earlier period analyzed (4/164).
• Changes in planned procedure creat­ed a vulnerable stage for mistakes.
• Mistakes involving electronic medical records were a new source of error (n = 17).
• The cause of 44 PSIs was unknown, leading the authors to recommend more thorough error reporting.
• IOL exchange surgery was reported in 45 cases.

Better preparation is key. To min­imize error, the authors recommend simulation training to better prepare medical teams for real patient en­counters. “The actions, behaviors, and communication skills of the surgical team are key to the success of surgical checklists and safety processes to ensure correct IOL implantation,” Dr. Steeples said. “Simulation training is important for teams to train together to enhance communication and build more robust systems.”

—Miriam Karmel

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1 Steeples LR et al. Eye. Published online May 13, 2016. doi:10.1038/eye.2016.87.

2 Neily J et al. J Patient Saf. Published online March 16, 2015.

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Relevant financial disclosures: Dr. Steeples—None.

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