Wrong site intravitreous injections are rare and linked to a variety of human errors

This retrospective case series study of a convenience sample identified wrong site intravitreous injections and how these errors occurred.

Study design

This was a retrospective small case series of a convenience sample at the Kaiser hospital system between January 1, 2019, and December 30, 2020. Cases were identified either as part of a formal institutional quality review or by self-report of the involved surgeon during quality improvement discussions.

Outcomes

During the study period, 4 wrong site intravitreous injections were identified among more than 147,000 injections performed within the Kaiser system. Errors were associated with inaccurate review of the electronic medical record, poor surgeon and staff focus, and inconsistent use of surgical checklists and timeouts. No long-term ocular morbidity occurred following any of these errors.

Limitations

This is a convenience sample, which may undercount the instances of the event.

Clinical Significance

Although the event rate is low, it is important to develop a team-based approach for verifying the correct site for intravitreous injections since each case in this series was preventable.