1. Intraocular lens confusions: a preventable "never event" - The Royal Victorian Eye and Ear Hospital protocol.
- Author
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Zamir E, Beresova-Creese K, and Miln L
- Subjects
- Hospitals, Special standards, Humans, Ophthalmology standards, Practice Guidelines as Topic, Victoria, Cataract Extraction standards, Clinical Protocols standards, Critical Pathways standards, Lens Implantation, Intraocular standards, Lenses, Intraocular, Medical Errors prevention & control
- Abstract
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., (Copyright © 2012 Elsevier Inc. All rights reserved.)
- Published
- 2012
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