Medical Errors: Wrong Intravitreal Injections

Journal Highlights

JAMA Ophthalmology, October 2021

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Vora et al. investigated a handful of medical errors involving intravitreal injections at their institution. Although they found that no long-term ocular morbidity occurred, they emphasized that these cases underscore the need to establish and consistently follow safety practices.

For this retrospective study, the authors identified four cases of wrong intravitreal injections that occurred between Jan. 1, 2019, and Dec. 31, 2020, at Kaiser Permanente Northern Califor­nia. During that time frame, the institu­tion’s retina specialists performed more than 146,000 intravitreal injections.

Two of the four cases involved injection into the wrong eye; the others concerned medication errors (wrong medicine or wrong dosage). In evalu­ating the four cases, the authors noted that, in each instance, the surgical team did not review a preprocedure check­list. In addition, no surgical pauses or preprocedure timeouts took place, and the patient consent process was inconsistent.

The authors recommend that retina specialists develop a systematic process that 1) informs the staff of the injection plan; 2) ensures that patient consent and marking are handled properly; 3) includes a preprocedure checklist; and 4) incorporates a surgical pause or timeout to ensure that all information on patient, eye, medication choice, and medication dosage is correct before continuing.

The original article can be found here.