JAN 08, 2013
The authors report seven cases involving implantation of the wrong IOL during cataract surgery for which the cause was human error. The cases illustrate how initial errors, some occurring before the day of surgery, can result in a cascade of events culminating in the implantation of the wrong IOL.
The cases occurred between 2006 and 2011 at four large ophthalmic training institutions. The causes were the generation of incorrect IOL printout or calculation sheets, poor communication between nurses and surgeons, transcription error, or, as in one case, a manufacturer's labeling error.
The authors note that the institutions where these errors occurred face a common challenge: how to institutionalize a culture of safety that will apply equally to part- and full-time faculty and to residents and fellows in training. That challenge is in turn magnified by the relative rarity of these errors and the multiple paths that may lead to such an error.
They add that it is critical to be aware of the various potential causes of IOL selection errors. Although the most critical moments in preventing IOL error occur in the operating room (OR), it has become equally apparent that the path to IOL error often begins earlier. As such, quality-control efforts must begin at the time of initial measurement and decision to undergo surgery.
They recommend the following practices:
- Documenting in the medical record a surgical plan regarding IOL type and general refractive target.
- Verifying the presence of the intended IOL, in particular any special-order IOL, in the OR before the patient is taken there.
- Using two patient identifiers (name and either date of birth or medical history number) to match the name on the IOL calculation printout to that of the patient.
- Having the surgeon clinically reconcile the situation or repeating the measurement if the difference in axial length between the two eyes is > 0.3 mm.
- Minimizing the use of IOL order forms that require manual transcription from the IOL printout.
- Transmission of properly labeled IOL power calculations with name, date of birth and medical record number before the patient enters the OR if the IOL calculations are missing on the day of surgery.
- Verification of the IOL on the day of surgery.
- Having an IOL-specific "time-out" period in the OR before surgery.
- Ensuring that only the IOL for the patient currently undergoing surgery is present in the OR and that any unused IOL is removed from the OR after each case.
The authors conclude that ultimately a team approach-one involving the efforts and concentration of ophthalmic technicians, surgical schedulers, operative nursing staff and surgeons-is required to reduce the rate of IOL errors. Final verification steps on the day of surgery will always remain paramount as the last, if not best, way to prevent implantation of a wrong IOL